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The Gastroenterology OSCE Station Part 1 - OSCEazy

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Summary

This medical teaching session is designed for medical professionals to learn about hematemesis and its various causes. During the session, attendees will learn about the various causes of acute abdomen and be given clinical vignettes to spot diagnose them. Discussions will then focus on ways to differentiate between the three main causes of hematemesis and the best approach for taking a focused history and initiating a management plan, including pertinent investigations. Attendees will then be given information on the associated risk factors and how to assess them and ascertain the severity of pain.

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Learning objectives

Learning objectives:

  1. Understand the common causes of acute hematemesis and how to differentiate between them, including peptic ulcer disease, variceal bleeds, and Mallory Weiss tears.
  2. Understand the risk factors for each of these common causes.
  3. Learn how to take a focused medical history from a patient presenting with hematemesis.
  4. Recognize the warning signs of a severe bleed and when to initiate further investigations or interventions.
  5. Identify key management plans for each of the common causes of acute hematemesis.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

find out all ski Sanders joined our ski team to be one of the lead lectures on the series. And very excited Torto give you the first pack of gastroenterology. Also be station. I saw 100 over to it. Get a show, everyone. Ansarullah on. Do, um today we're going over like some really high. You think that may come up in your gastroenterologist or ski station, so going to be going over the acute abdomen. So in terms of GI bleeds after pain change in bowel habit and John this so the most common conditions you're likely to get Noski how to approach them, how to present them on gum. How to tackle the station. Basically have any questions at all. Please put them down and chat. We have a break in between on, but I think this might take anywhere from an hour and a half to two hours so that with me. So let's begin with acute abdomen. So we have a 60 year old male, Mr John Smith, who presents to any with hematemesis. The task is to take a focus history and initiate a management plan, including part in investigations. So with when we're looking at somebody with hematemesis. Um, off. What I want to first want to do is to get a spot diagnosis. I'm gonna give you guys a clinical vignette on. I'd like you to give me what you think. The diagnosis might be in the chat. The first one is a 48 year old lady who complains of coffee. Ground vomiting is associated with burning and the gastric pain that is worse after eating. She's been taking over proving daily for about back pain for the last three years. What do you think That yeah, spot on just got a bleeding peptic ulcer disease. Peptic ulcer that start bleeding because of the hematemesis 59 year old man complains of Hematemesis. He also has noticed a dark discoloration of the stools recently and complains epigastric pain. He's known to have alcoholic liver disease. Parcel hemorrhage, Sports own. Yeah, yeah, spot on guys. Really good. As we're looking at his office, your Barrett's good old to be gastric to be there. Yep, pricey hemorrhage. 32 year old woman complains of Hematemesis following episodes of breath itching and vomiting. She feels dizzy and lightheaded in complaints of epigastric pain. She's just been a the pub. Lots of battery wise. Yeah. Amazing. You guys got this really good, Thank you. On 58 year old man who presents with breath toaster, no burning chest pain and coffee. Ground vomiting. He says he's been experiencing heartburn for about a year and has been getting worse. He notes abdominal discomfort after meals, and he owns a pub and drinks about four pints of beer and night. What could this be? So have you got it right? So basically, it's it's complication of having board to. This man has probably has gored, and as a result of Bad God, he's now got esophagitis. He's got reflexes is reflux esophagitis, which has caused an erosion in the esophagus. And now he's vomiting. Blood result. Yeah, really? Well, don't, guys, if you move on, Teo Hematemesis is acutely and how to approach it The main through differentials we're looking at today a peptic ulcer disease, Parcel bleeds and Marie Wise stairs. So how did they present differently? And how can you compare and contrast them so peptic ulcer disease? Um, the kind of hematemesis you the nature off the blood of the vomit is likely to be dark, and they describe it as dark and coffee. Ground is the word on do this is because it's it's not really a very big volume of blood there. Bomb it in, and this lot of their stomach gets mortified by the acid on becomes this like oxidized version and therefore becomes dark colored on. That's what they want it. If you can trust this to Variceal, bleeds embarrassedly to getting a much larger volume of blood that's being like spat out wherever the bleeders. And there for, like, there's there's no time for it oxidized, and it just comes out. So it's fresh red blood that's coming out with memory wise tear could be either really depends about It is, but you know the fact that they've probably been vomiting a lot before and Onda as a result, it could be fresh blood, or it could be called the ground. Um so usually also have abdominal pain associated with each of these presentations. With peptic ulcer disease, you probably get burning at the gastric pain because of the gastric acid that's irritating the's stomach or the duodenum with gastric ulcers. The pain is worse after meals, and we do deal alters, it improves after meals. This is to do with the acid again. So when you eat, you are triggering HCL secretion in your stomach. That's going to further irritate it and cause more pain, whereas when you have a do a deal, also, the food you eat is going to neutralize the acid and therefore lessen the irritation. And there for the pain improves. If that makes sense in variceal bleeds, it's sharp domino pain because it's kind of you've is. Could you cut it is ripped a vein. You ripped it and not bleeding, and it's really acute and fast on. It's sharp pain. Uh, Mallory Weiss test. Also, I like CVS a sharp pain because you are getting ripped yourself. Forget you erosive. You got to have a general pain. With all of these presentations, you can get Melena. It's not particularly common with any of them, but you can, because that can always make it a way down the gut and get to your stools and turn up is Molina, which is dark stools in terms of risk factors that can help you differentiate between these three main different shows. You're looking at a history of like a high H. Pylori infection in peptic ulcer disease or the views of incidents of an extended period of time. These are the major risk factors of peptic ulcer disease. Variceal bleeds. The's happen in people who have chronic liver disease. It's a complication. So these people have liver disease and then it gets worse and they develop portal hypertension. And as a result, they get Barris is. And if their liver disease, it's worse and worse, these viruses complete, which is what has happened here on. They will have, ah, background of heavy alcohol intake, alcohol abuse that would probably trigger the varicies to get worse in terms of memory. Wise tears, common risk factors are, firstly heavy alcohol consumption like they're recently in the last few hours. Hyper, um is the garbage or, um, that you get in pregnancy and even eating disorders like anorexia. Um, Andi, what basically happens is that you are vomiting and retching so much as a result of your alcohol intake that after a point, all this retching like rips you the mucosa in your esophagus. Uh, Andi can cause bleeding. That's what happens. So now that we've talked about the mail through defense feels how you gonna approach is the Noski. And how are you going to get this information out of the patient? What kind of questions are you looking to ask? So obviously you first want to address the presenting complaint. In this case, the presenting complaint is hematemesis. So you first warned to ascertain how much of the vomiting is a big volumes of small volumes. Like I said in variceal bleeds getting larger volumes. Where's and peptic ulcer perforations you might not get as much. What are the blood looks like? Is it coffee ground is a dark or is it fresh red blood? Is this the first time? If it's something like, uh, peptic ulcer disease, it could be happening for a while for a couple of days. But if it's something that Malorie wise, it's very acute. It's just started. This is the first time it's happened. Is there any Melena? Is there still dark eyes? They're older, and they're still This can be indication that obviously the blood has moved on. They got to their stools. Um, are there any nose bleeds? Or this is an important one because sometimes if somebody has epistaxis where they're bleeding from the nose. This can make their way down. I got through the esophagus on be present, as as either Melena or they might vomit blood. So and really, what's happening is it's just a nose bleed, so you kind of want to ask about that as well. It is an associated pain, so you can use the type of gum abdominal pain like we discussed earlier to differentiate with. It's sharp whether it's burning, whether it's constant and diffuse. Those can help you differentiate what kind of college it is on. You want to use the pneumonic Socrates, which you might have heard off site onset character radiation associative factors. Um, any of exacerbating factors and the severity of the pain is in the morning test. Ascertain pain and, uh, what it's like. Also, you wanna know any recent history of illness infections that could have triggered the problem in the first place. Now you got a good idea off the hematemesis itself on the nature of it or what? Where it might be coming from. You want to do a general system review because this is a very acute presentation, and you want to be able to see that anything else going on, Um, and you kind of assess the rest of the body so USS the pain, which could be in the abdomen or the chest or anywhere else, depending on the patient. Um, you can get other abdominal symptoms like bloating. They have dyspepsia because the disease and things John this if there's a liver cause or like he monitors or something which you don't have to get the eye bleeds with. But it's something that's worth screening anyway, because if it's g, I dysphagia a sign of malignancy. Office official cancer, which very rarely presents with joy, bleeds. But it's something that's worth asking its right like fatigue, which is a sign off chronic bleeding, maybe to their bleeding. Small amount of a large period of time. They could develop anemia. Uh, shortness of breath again, lots of blood, um, night sweats and, like That's nice is again is a red flag, uh, kind of kind of malignancy related, um on did so is unexplained weight, loss of loss of appetite, and things also screen for fever for any kind of infective cause that might be happening. Ascites or signs of liver disease, constipation and diarrhea change in bowel habits. If they complain of Melena and things like that in terms of the past medical history, you want to know, uh, have they got a preexisting liver disease? Because this is more likely to make a diagnosis of like, variceal bleeds more likely, for example, because it's their liver disease that has been decompensated or exacerbated any history stomach ulcers? Because if they do have a history of stomach ulcers on there, the chance that they could have one that then perforated and his are causing a bleed. Previous cancers can predispose people to developing a new cancer, and it's there for a risk factor. Um, on D his your retina and a wreck. See, A is again associated with memory wise stairs, and we discussed earlier again. Bleeding disorders is a really important thing to state. When you're asking about taking his tooth in somebody with a G, I bleed because any kind of bleed you want to rule out the fact that the cause of the problem is not just like an N H, cause that they already have, where they have problems, clotting or problems or coagulation or something, or there's some kind of trauma feel. Yeah, so you would definitely want to ask if you have any, like inherited bleeding disorders or human few years of things as well as our call abuse. So this would kind of either relates to their liver disease where they have the disease and the continue to drink. Or they had a very acute episode of drinking lots on that can cause things like a realized their irritation off this office. And also you want to look at their social, family and drug history. Like you would say, it's a social issue. You want to ascertain alcohol intake, like I mentioned earlier, very important. And the drugs, including and said steroids' anticoagulants bisphosphonate. It's are important because they can irritate the mucosa in your guts. Andi can predispose you think like esophagitis on just a rose version of the mucosa that can lead to bleeds iron. If people take iron tablets, This can give make their stools of black in color, which you know the right thing is Molina. But really all they're doing is taking iron tablets, which is making their stool black, because I could be misleading so definitely ask about iron tablets. PPR use It kind of gives you, if you ask. Have you ever taken something called sleep Resolve? This kind of gives you an idea that they might have gored from the past. Or they might have peptic ulcer disease in the past or dyspepsia. And I can help your diagnosis. Your differential. Recent travel history have ascertained things like hepatitis, which is less likely to be the G. I bleed, really, But you live looking for infective causes potential in fact, of causes. Here on on day family history of cancer, bleeding disorders, like I said, inherited problems that could be causing the bleeding. Okay. And so now you have all this information you taken. How do you presented to the Examiner? How are you going to consolidate all of this thing about an Oscar? Is that when you present your findings, you're not just regarded dating everything you've learned our that patient on their history, you can need to pick out the most relevant facts. What do you think are the most relevant that a senior would want to know in order to assess to patient father. Right. Um, on. So there's we've developed that we've developed this kind of flow chart to help with that. So the first thing you do obviously is, you know, patient details. You want to make sure you want to state the name, the gender on the age of the patient right on there. Keep presenting complaint. So in this case, that would be our something like, we have 68 year old male John Smith, who is presented with hematemesis. Right. That's because it's a then you go on to talk about the history of presenting complete. So around the hematemesis is the key points about the hemodialysis that would make a difference. So you'd say 60 or it. Or 68 year old John Smith male who presented with Huma TEM assists. They could say he has started about an hour ago when he was at the pub on do it associate it with, um, healed, complaining off the shoes, abdominal pain. So those are the main key fax that you need to say about the complaints. Um, so just to clarify, I'm painting. They've been yet of somebody who's presenting with of our CF bleed. Do you do a liver disease? Okay, so, um the makeup. It's hematemesis with abdominal pain. And then you want to ask you this thing called relevant negatives? Can someone in the chat tell me what they think? I mean by relevant negatives when you presented a history red flags like a bit more specific than that, maybe factors? Yeah, exactly. Perfect. So there things that exclude other diagnosis. So if you want to exclude him red flag symptoms or other differential that you want to exclude that you've screened in the history, you can present those in this case, I could be like he had hematemesis that sound an hour ago. Um, it's a significant volume of blood. So see it with abdominal pain. He has. There's no history of retching or vomiting this kind of rules out not as a rule out. But this kind of makes a diagnosis of Mallory Weiss tear less likely. Um, also you can say maybe that he has no history off peptic ulcer disease or dyspepsia, which may make a diagnosis off. It's off a giant cysts or perforate a public, also less likely things like that that would help you point towards the diagnosis. Then you want to mention relevant past medical history on social history and drug history and things that would support the most relevant things on the key word again is relevant. Don't just say everything like you don't have to say he had a neck of, um, fracture five years ago like that. It doesn't matter. So you say things like John has had. John has been diagnosed with alcoholic liver disease one year ago, and he's currently taking warfarin for his age of formulation. Those are really relevant because our colleague liver disease means that my predispose him two of our scale bleed varicies and rice you bleed on. The fact that he's taking warfarin means he's on blood thinners, which could again predispose into bleeding more on you present the most common ones on the fact that he runs a pub, which means that it's a good chance that you know he has ongoing history of alcohol abuse that he continues to drink, which can make his liver disease worse, then want to present the ideas, expects, ideas, concerns and expectations that you've elicited real patient what they think it might be, what the main concern is on things like that, and then you want to present your differentials. And I would just pick three differentials, the most likely 11 that is less likely, but quite similar on do the third one is something from a different different system in the body. This shows the Examiner that you've narrowed it down something you think is the most likely answer. Show that you're considering something else. Um, but also show that you're thinking wider for end into another system. So, for example, on with this with this guy who's vomiting blood, you could say that my top differential would be that this is suspected variceal bleeds. Um, but due to the volume of his bleed on his alcoholic liver disease history, however equal to be a model rewind, start giving the alcohol intake and another differential from another sister that you can think off. Um, I think one of the top of my head right now, But just just consider doing that. Terms of investigations. You're gonna be off how to go about this in terms of any GI I bleed, no matter what bleeding is, if you suspect a g, I bleed. There are certain investigations you have. You have to do no matter what you think the correct diagnosis is. Okay. Anybody tell me some bedside investigations you would do for GI Bleeds. Suspected you, please. On the bedside ABCDE. Yeah. Perfect. Exactly. Yeah, whatever. That helps yet keep going after exam yet. Perfect. Close your examination. Digital rectal exam. Perfect. Yeah, And he has a toe. Yeah, You could do two sats that come on 80. Ultrasound is more. It's not really would that immediately. That's not indicated. Everything. Um easy, Gi. Yeah. Perfect. Yeah. Go to guys. Great to the first thing you will do is treat. This is an acute abdomen. Right? So you want a B, you're 80. Assessment. We'll go over that in more detail in the next few sides. Uh, definitely. Do the eighties assessment that you weren't taking easy gi. Why would you want me see GI in a G? I bleeds. Okay. Someone's just like anybody know the answer to why? What was easy? GI show you in G. I bleeds with me as you, um Sinus tachycardia. Exactly. If somebody is leading out there, probably going to be hypotensive, and therefore they're cardiac output needs to be maintained, and they will become tachycardia in competition for that. So you might see Sinus tachycardia on the HCG, for example? Yeah, but thanks Do a full abdominal examination to acetate. Any tenderness, Any other signs you can pick up on, But we'll go into more detail on definitely do a digital rectal. Say you do a digital rectal examination. This is to ascertain any Melena on that may have that may present as well. In terms of bloods, you want to do a full blood count. A full blood count will show you a couple of things. One you'll be able to see whether they're anemic a toll if they haven't raised MCV sometimes are called consumption can raise your MCV um well on. But, uh, if there's less ineffective cause my leukocyte Asus less like a job lead. Really? Um, on D if they have liver disease, then they're producing less from before eating and therefore less. You get low platelets as well. If you have chronic liver disease you do use and these guys What are we looking for? You. You are using these. Why that's so important to do. Use these energy. I bleed. What you looking for? I'm looking for one answer. Rays. Urea. Yeah, Perfect. Cuz a raise your ear is a very important indicator for G I please. Um do you look for that in you sneeze, you don't clotting screen as well because they're a good indicator off liver function. I could also look, for if you have any underlying clotting disorders on that predisposes them to bleeding out, you definitely want to do a group and save and cross match. This is in case you need a blood transfusion. And most likely if they have a significant amount of blood there losing, they will. So, um, a group and save basically is when you take a sample, that blood to ask him what the group they are, see if they have any antibodies in their blood that may react other bloods, blood types and a cross match would basically be when you literally put the Dorner's blood with the patient's blood and see if they react together to make sure that the patient wouldn't react about transfusion takes and possible, and that's what he would do. Uh, is there any imaging you should do for any GI I bleed? Not specific to any diagnosis. Any imaging you could do images. Endoscopy, Yes, yes and meals erect Chest X ray. Perfect. Yeah, he will be Iraq's you definitely to do it. Erect X ray, because this will show you if there's any like a pneumoperitoneum. If there's any air and the abnormal cavity, for example, if they have a perforated peptic. Also, that's going to lead a normal cavity, and you'll be able to see that on Texas Iraq Chest X ray. Oh, that in terms of a bleeding Catholic, also in particular on others have special tests you want to do include a H. Pylori urea breath test, or it'll religion test to confirm the diagnosis of that. If you suspect that that might be the underlying course, uh, and definitely endoscopy as well for a Mallory Weiss tear on because well, as a variceal bleeds you definitely to refer them for endoscopy. We'll get to the pathway for these in a second. Okay, something you could get asked your skis is to explain the endoscopy procedure to a patient who's going to have an oscopy. So you got to brush through the key points need to mention when you're explaining the procedure. The first thing you always do when you know chatting. Converting to any patient is always wash your hands. Introduce yourself, confirmed patient details and explained the procedure. This is the acronym wipe. So watch hands, introduce yourself patient details and then explain the procedure right on when you're explaining things are very good format to you that you might have learned is called chunk and check where you give little bit of amount of information to the patient. Then make sure that we've understood and they have no questions so far. And then make sure you understood it and then continue giving another chunk of information. And if you work in small chunks, you making sure that they don't get overwhelmed with all the information you're giving them and you can make sure that like, you know, you build a good report with them and it shows that you care. So when they first come in, you want to know if they know when OSCOPY is and if they know why they're having it. So you ask those questions. Do you know where you come in today and what You know what the procedure and then you need to explain to them why they're having it. So if somebody, for example, is come in with, um, like coffee God, Mom is saying to be like, um, we think you must. We would like to do an oscopy to ascertain whether there's kind of define it, causes of the bleeding in your stomach or esophagus, kind of what you say. And then you want to explain the procedure itself and what it involves so you can tell them that it may be uncomfortable and therefore you can offer them sedatives or local anesthetics. This's an option. Not everyone needs to have it. They will then be asked, lie on their sides on a camera in a fiberoptic to will be passed down the esophagus into their stomach and duodenum to look for any signs of pathology or any they could identify any sites of bleeding. And then it and the doctor would also be able to take a sample off the tissue to drawn for the tests on. To ascertain a diagnosis on this whole process might take about 15 minutes. You need to explain to them that they're so certain points that we need to do to prepare for this procedure. One is uh, the need to be fasted for eight hours prior on been fasted. They can't. They can't have any kind of food. Nothing that started clear Liquids basically just water eight hours prior. They need to have, um someone who's going to take them home off the procedure. If they professed a shin, I think specially gonna have, like, sedation on, Do you need to go on to explain the risks and complications, So that's basically extending it to them. But here, the key points me to mention in terms of medical point of view. One is that two weeks before the procedure, they need to have stopped antacids ideally, because this would, if they're if they're still taking antacids. This could hide pathology in their stomach. Uh, duodenum. So, ideally would be good if they stopped antacids two weeks before on dropped eating eight hours before have explained the risks. There are risks of perforation and bleeding and infection. Um, well, and in this procedure, it's very rare, but it can happen in terms off the sedatives. They could have midazolam, which is given on day. It's basically like an anxiolytic drug to calm them down because it can be quite uncomfortable and can make you quite anxious. Lidocaine spray, which is number, throat area so they don't feel as much. Um, Onda. You can explain to them that procedure will involve continuous suction happening to get them a clear view off the stomach. You'll have to advise that if they are taking said, it is, especially this means of the car drive for about a day after on dydee a li I'm not consume alcohol either, as this might irritate them. You, koza and definitely arrange followup connected kind of Teo. So see how they're doing. Let's go over some endoscopy is, um so some here you could see this is what a bleeding gastric ulcer would look like. It's really bad. There's this thing called the forest classification. I don't think you need to go to that agency all skis, but it helps you classify how bad the other is. How much is bleeding out? This would be like a forest one a plus gastric ulcer, which is the worst where it's like bleeding out and spouting out blood. This is a duodenal ulcer. The main thing about it beating gastric, also the main risk it poses is that it has the risk off becoming malignant. Um, duodenal ulcers did not have his risk. And that's what's really important that you arrange a followup clinic for people who have bleeding gastric cancers because of the potential for it to become malignant. You don't have esophageal. Various is the one on the left is not bleeding. It's just really bad viruses. But the picture on the right is like and it's off bleeding. Esophageal Barris is a Z concede we on when you have a Mallory Weiss tear and you can tell that it looks very different. It looks like someone's got and ripped out the mucosa. That's exactly what happens. It's like laceration in the throat because of all the retching that somebody is doing, let's talk about the acute 8 80 management off Upper GI Bleeds. So a airways Can someone putting the chats? Uh, what? The most important thing to do in terms of airway management is it's actually blood's okay? Yeah, And the, uh, but was the first thing you do when you do 80 and you look airways check. The patient is talking Exactly. Do you want to make sure the airways patent on the easiest way to do that, to see if they're talking. Because if they're talking like they can, they can get Aaron and out on there's nothing blocking the always very good. Yeah, Perfect. You might need to perform some jaw thrust maneuvers are maneuvers, toe get a better look, but definitely there. Talking. And if the airways beaten brought breathing looks insets? Yeah. First page through eight. Yep. Just movements. Okay. Anything else? Until breathing? Rest effort? Yeah. Oxygen sides. Okay, so oxygen. Sounds like you're all set on a respiratory as well. Also, just liquid drinking deviation. Um, and you want to perform in arterial blood? Gas is Well, um, it's part of just the 80 political on. Do give them high flow oxygen. Think they require it in terms off circulation. What do you think of the most important point is to note in terms of a G. I bleed situation, shock signs. Okay. Shock signs of signs of hypoglycemia, right? Yeah. Okay. Anything else? BP. Yep. IV access. Perfect. And the other told guys easy, gi. Yeah, you to read on the CT after, But I said you mean Okay. So when you're looking at a bleed. The thing you're worried about acutely is that they're losing fluid. They the fluid balance is disrupted. Right? Um, Andi, the best way of looking for this is things like cap refill. Look for the peripheral pulses. Look at the mucous membranes, the cold, fluid output to look at. How much the urinating are they dehydrated? All of these are signs off. Hypovolemia should look for that first, then check for heart sounds and then you want to establish intravenous access as soon as possible with a wide bore cannula. You want a wide cannula? Because in case you have to give him a blood transfusion, you can give them a lot at once. A lot more fluid. Uh, take your bloods. Definitely. Like we mentioned earlier for the things you want a certain thing group in saving cross match soon as possible. Because if they're bleeding out, chances are they're going to need a blood. They need a blood transfusion. So you need to start the blood transfusion based on their hemoglobin leveled on. How much blood do you think they've lost? If they're actively bleeding on how a platelet count of less than 40 police 14 and paranoid you to give them platelet transfusion. Consider of FFP. Inquire precipitate in patients who have a great a PT or a B c D. On but also patients. I've heard warfrin I actively bleeding. Consider pro forma complex concentrate in terms of If you suspect a variceal bleeds, you go ahead and give them IV. Totally press in on IV antibiotics. I'll get to that. What those are my second next side as something you just have to do if you suspect it on stop anticoagulants because obviously you want to stop them bleeding to stop and said, Stop and the regular it's. And if they become unresponsive at any point, just like 80 Political, you want to stop and do CPR if there's no signs of life. What about, um so in terms of D, you would look for after leveled off those times for alert, voice paid. Unresponsive, which is essentially just kind of ascertaining there. Say that the mental status you want to check that pupils equal reactive delight. This would rule out any problem any like neural pathologies like infarcted regions that brain, for example, that because in pupillary reflex defects capital, blood vehicles again is good for ascertaining several levels of consciousness that, um and finally the you want to look for signs of liver disease in these patients that could help you with the diagnosis really quickly. So, like if they've got signs of bruising, this could tell you they have plotting coagulation problems on that particular day starting the va as well in the ascites and kept medicines Could tell tell you that they have portal hypertension. Did you did a liver disease on do purple edema as well? Uh, check the temperature. Just see how perfused they are. Guess that girl to come on a circulation. Perform a digital rectal exam. Definitely stay from Molina like we discussed earlier. Your analysis as well. You can find blood there and on d. Also definitely insert a catheter. Have more than your output Really important because you're on our part is a very useful way off ascertaining how much fluid this person is losing other dehydrated. How much need to like give them fluid? Replacement is what and definitely organized urgent discopy. Anyone who presents with suspected about your ability to get an endoscopy. So let's talk about how you present this to an examiner. So, um, it's called SBR and SBR is kind of the format you use in presenting emergency scenarios to a senior. So this would be situation background assessment recommendation. Okay. On the left, I have the clinical vignette off example. Patient Oliver Roberts again. I'm using the vineyard off a suspected variceal bleeds. And how are we going to present this PSA? First, you want to introduce you to pick up the phone, Be like hello? I'm asking is e the f Y one doctor on call in the emergency department? This is the medical registrar. Introduce herself now, you just maybe like, yeah, what's happening? Situation. And you say I'm calling you because somebody is presented acutely and well, Oliver, about 64 year old man. So name, age gender has presented with a suspected variceal hemorrhage. What you think it is? Background. So give the most relevant details from there by grounds. Right? Two hours ago had labs. Remarks is how much he vomited. Born to the point of bloods and the associated symptoms. That abdominal pain. This's the first episode of human hematemesis he's had. And then you want to give any vitamin past medical history. So alcoholic liver disease He runs a pub and continues to drink afternoon. The day doesn't smoke on any blood test results that are significant. So his allergies were deranged little bit on Grazer serum urea, but it's probably just started to normal. So now you've given what you think the problem is on but basic clinical background for what you think might be happening. You don't want present your assessment of this patient's clinical examination. Um, and your new school would come in here. So here you say he has a new score of two. He stocky Kartik, 128 beats a minute respirations 20 oxygen SATs 96. He's alert and a febrile like the key things you want to mention here on. Do you want to say what you've done about it? Acutely. So according to a t. E, you want to say what you've done is you've started. I feel Bullis and you started a blood transfusion and in because he suspects variceal bleeds you like I mentioned earlier. You say you started IV tell you, press in on prophylactic are the antibiotics again, we'll talk about possible bleeding. More detail in a second, but it just telling the doctor what you've done. And now you've given him a bag out of the patient, How you acutely managed it. And now you want to recommend What do you think he should do? Further? If you'd say I think he says suspected of are still hemorrhage and need our assessment in the form of an endoscopy where you can consider in for endoscopic band ligation. And is there anything else you'd like you need to do for the patient? And can you please review them? Assume it's possible. So this would be an example of a nasty presentation in an acute GI bleeds on. Do you want to be as as concise? That's possible. And just mention the most important things and what you've done about it have that make sense. Great. So here is the nice guidelines pathway for the management of acute suspected upper gi. I bleeds. Okay, Somebody comes in with, uh, hematemesis is or and you're like, Okay, I think that would help with GI bleed. First thing you do like we said, is a B C Z assessment. Right? Uh, we should do that. And then next thing you do like we discussed is well is you want to stop any anticoagulant in stop Any NSAID, too. That would exacerbate the bleeding to stop those immediately to control the bleeding. Um, Andi, they're like we said, you replace their fluids and most importantly, give him a blood transfusion if they need it. Especially based on how much they're bleeding and any other blood products that need transfused. And then what you want to do first after that is ascertained whether this is variceal or not. Okay, Can someone tell me in a chat what you would do if you think it's suspected variceal bleeding start our be totally present. Exactly. What else would you start and to be our sex? Exactly. The first thing you do is like Is this our seal? I think it might be Okay, Go. I will tell you person on prophylactic IV antibiotics is anybody know? So total person is a vasopressin of a depressant. A log on. Basically, what it does is that it increases the smooth muscle tone in your arteries. On this decreases the amount of blood getting into your splanchnic veins and therefore reduces, like the Variceal demon essentially. But can anybody tell me why we use Ah prophylactic IV antibiotics? In this case, words Was it for SBP? Exactly. So if in this case you want to extend possible, you want to prevent spontaneous bacterial peritonitis and therefore you have perfected I IV antibiotics because that would be bad. That would be really fatal. Could be fatal. So you prevent that? Um, by giving these drugs, these are the two main things you remember. If you don't think it's variceal bleeds that Okay, move on. And you do this thing called risk assessment with the glass go Blatchford school. The Glasko blood for school is basically a school that would help you ascertain how acutely what? What? How bad this patient is acutely like it'll tell you whether they can be just be discharged, reviewed later, polyp clinic or whether they need to be seen a hospital right now. Okay, So if they have a score of zero on this class of glass Blackfoot school, you can consider only discharge, send them home and arrange for the endoscopy for them to come back at some point next 24 hours. Okay, So, like I said, everyone who comes in with respect. A qd upper gi I bleed gets an endoscopy if you don't think it's, um, acute based on your Glasko bad foot school. If you get a score zero, it's fine. You could consider older discharge and, like I said or injured oscopy the 24 hours. If the score is more than zero, then you admit them and often and oscopy immediately after resuscitation. Okay, this tells you it's more cute. It's probably more dangerous and needs immediate attention. So and this is going to tell you, um, if you have non variceal bleeding, you go in and ask optically, and you can treat it that way and that would you also want to do is give them PPI therapy. Ah, lot of people sometimes give PPI before endoscopy, which is not good practice, because when you get on PPI eyes, you're basically going to cover up. And he also said any pathology is they might have that would be relevant. And so when you go in with your endoscope like it might be hidden because you're giving the P B. I's and therefore you always give PPI after endoscopy, which is what the guy Let's just if they're still bleeding after endoscopy, their treatment on PP eyes then you can read. We consider them for a repeat endoscopy. Further surgery or intervention. Radiology if they have a variceal bleeds, uh, you do this thing called band ligation? If they have any esophageal varices, you could use endoscopically. Or if they have a gastric viruses, you could inject on beauty I'll to sign or I collect. Well, we should help. So this is the nice guy lines pathway for acute suspected upper GI series. That makes sense. So how do you manage some of these conditions? Longer term, you saw that you saw the problem. Usually what happens on the time to these patients and somebody who has peptic ulcer disease there things you could mention all ski you in an Oscar. You want to go conservative medical and surgical management. So for peptic ulcer disease, conservative management would be things like Avoid eating spicy food because I could irritate your stomach, avoid like a reduced extent possible or e or ideally, avoid alcohol intake again and irritant um, give them advice and smoking cessation, antibodies, caffeine and take all of these things unknown, exacerbating factors or peptic ulcer disease. A medical point of view. You put them in high dose PPI eyes. Um, long term on, do you? You might want to do symptom control. So if they have heartburn, you can give them Gaviscon, which is an antacid to control the heartburn. If their age pillory puzzle positive, you wanna start eradication? Therapy of allegation therapy includes antibiotics on PP, eyes like aggressive treatment, for I think 10 to 14 is not really. But, yeah, it's aggressive treatment with PPI on antibiotics if they have esophageal various is, um or honestly, this advice is for people who have chronic liver disease in general. Because if you have esophageal Barris is you probably have chronic liver disease and portal hypertension and conducted management would be reduced alcohol intake or avoid possible you could. In Oscar, it would be really impressive. You said things like I would encourage them to join ankles, alcohol support groups, um, or charities that help people who are trying to withdraw themselves from excessive alcohol intake. That sounds really nice to say, because of their liver disease. You'd say you want optimize their nutrition with vitamin supplements and definitely organize a follow up endoscopy to see how they're doing down the line on to make sure that it doesn't come back. We'll get worse. The viruses in terms of medical treatment, the long term treatment for esophageal various is actually are 32 blockers on berry. Specifically, they're non cardio, specific Peter Parker. So the propranolol, Because if you suddenly stop preload that's cardio specific and would not really help. Your Barris is because viruses on in the heart um, it's a non cardiac specific Peter blockers like propranolol, a long term treatment of viruses. That's upper GI. I bleeds, guys, Um, that's the first presentation. I'm gonna have a small break here. Let's say you come back in three minutes, it will come back to win. It's to eight. Um, but and we'll cover Abdo ain't changed about habit and joined this rosem stuff, so no, thanks. Dude. You guys take a break. Come back, Curly. So one is about more time efficient than I am, so that's a good thing. Like, you just have one on there. Not usually I end up taking it going into like a 15 to take a break. So he's back. Um, will you repeat the previous sessions? Uh, no, not until next year. Sorry. Um, you can find the recording. His own medal. Um, worst thing again. Okay, so that's once a patient who presents with abdominal pain. Uh, this is a very genetic presentation. It could be so many things could from so many organs. So how do you know diagnosis? How the approaches the Noski. So first, let's talk about different areas from where abdominal pain could present. Where do people complain of the pain? If somebody complains of epigastric pain, Um, which is in the center, just above the umbilicus above that region. Peptic problems. Think of the organs. There's your stomach. So you get public of the disease. Pancreatitis. You could even have some, like target problems like my little infection can present with epigastric pain, esophagitis and guard like we talked about as well. If you have a right upper quadrant and left upper quadrant pain, you want to think of your kidneys, for example, to a real colic could present with, um, upper quadrant pain on the right left gallstone disease in the right, because the gallbladder and the liver and the bile ducts. Um well, is pneumonia. Sometimes it can present in the peripheries. On the left side. You have your spleen's. A splenic injury can present there. Can someone tell me some causes of right? Lower quadrant pain, Right. Lower quadrant. Appendicitis. Yet a pen. Yet? Anything else? Crone's disease yet? Um, ecological amea ectopic pregnancy or retardation? Inguinal hernia. P I d. Yeah. Perfect. Guys got off. Really good. So right. Lower quadrant pain like you basically mentioned everything. Um, all of those things. What about left? No, According pain. Diverticulitis? Yeah. Perfections. Main difference. Exactly. Good, Onda. What about if somebody presents with periumbilical pain or like a hypochondriac? Pain Have a country and pain only appendicitis Yet yet Triple A exactly very good. And it's a perfume bik, which is bottom down. That's more. Maybe some gynecological or obstructive problems. Perfect. Now is your own idea. What organs are there on what kind of problems that can present in different types? What? Where different pains in originate from. This is kind of most common things you might see, but if somebody has pain, that's kind of generalized diffuse. They can't quite localize it. You like it? See things like peritonitis Where on examination there. Guarding on. Do this conducive things like perforation on batteries? Kenya. If they have a bowel obstruction as well, it could be diffused pain. I Bs also is, like not very easy to localize. On DKA as well is diffuse, generalized abdominal pain. So this is about diagnoses for abdominal pain. Ah, 48 year old lady complain of right upper quadrant pain. The pain started three days ago and is worse after meals. She's also noticed some pain in her right shoulder. She has a B M I of 32. I'm seeing lots of biliary colic be click. Yeah, it's for time That has been chronic, most likely a 22 year old male complaints of right lower quadrant pain. He says it felt initially crampy or was umbilicus, but it's since moved and become more constant. Europe was one episode of vomiting, saying, a verbal yeah, per perfect appendicitis. The pain eventually starts in the middle on, then moves to the right lower quadrant on associative vomiting. Usually very good. 31 year old woman complains of retro sternal burning pain. She's 24 weeks pregnant, she says. She can feel of food. Come back up during meals. Sometimes she's struggling to take afternoon naps of lunch as the pain is worse. Then what do you think this could be? Yep, perfect. A pregnant woman can get Goard's Because of progesterone. The progesterone can relax the's office. You think her and make you more prone to reflux disease? A 40 year old man complains of right upper quadrant pain. He's jaundiced and has a fever examination. Reveals tender hip part of Megaly Had he's recently returned from a trip to India? Hepatitis. What kind of appetite is, do you think? Yeah, what kind of hepatitis? Hep A. Yeah, exactly. So this is most likely given his travel history, where it's a finger or a bone disease on their four. Travel to these countries like India. Um, might you might develop. But I just a fraction, Um, a 25 year old woman complains of right lower quadrant pain. So she's been feeling dizzy recently in the notice, um, breast tenderness. On questioning, she said she had her period bleeding has been less than normal. Examination reveals lower abdominal tenderness. There's a gastric cause. I know you guys are on it. This is in fact, next topic. Pregnancy. She's got some Got the sign of pregnancies. In fact, the breast tenderness. Can lot of women get breast tenderness early on in pregnancy? Do the homework due to the hormonal changes on on what she's describing is a period bleeding is on. Actually, her period that's just spotting you get early on in pregnancy, so it's not period blood Onda lower abdominal pain as a sign of a topic. Pregnancy. Yeah, good stuff, guys. Very good. So here's the table with the most key acute abdomen pain presentations and the key characteristics off these pains. I'm not gonna go through all of this now because taking ages, but there's something you can look back to later on. It's really helpful because it gives you like the key differentiating factors for each of these kinds of diagnosis. My goal was a go over some of them today and some amount of detail. Um, so in terms of taking a focus history, I've messed up the animation. That side apologies the questions you want to ask about the abdominal pain as usual, you want to ascertain Socrates Okay, we talked about earlier on in terms of the main questions you want to ask about. Abdominal pain is one is the pain. Constant is quality. Does it come and go? Um, I was it there all the time? That could point of things like biliary colic or real colic or even things like bowel obstruction to be colicky pain. How long does it last? It lasts just for a little while after meals. That could be, uh, like, Maybe that can also it's there all the time. It could be something else. Um, the Yeah. How was the pain? Like after meals? Like we said, um, up of gastric ulcers. Get worse after meals. Do the labs get better after meals? Um, how is the pain around your period? This could indicate any kind of gynecological cause of the pain. Um, that could be psychical. Um, any changes in stools? Um, if somebody's got IV S o r i b d, they might notice a change in their bowels and some kind of bleeding diarrhea, flatulence if they got, uh, you know, uh, so give that, um, this past ever difficult to flush. That could be a sign of Seattle area. So celiac disease consent. Like people present commonly with Strattera despotic, so relieved the pain. So if somebody's got constipation that's causing them pain, then when they go to open the bowels, this could relieve the pain. For example, even an eye bs a common finding. A typical presentation is where defecation relieves the pain. Any vomiting. Vomiting is really actually very helpful in that your abdomen, because if the vomiting started before the pain started, then it's less likely to be acute. Abdominal problem at court. Something else is the primary problem. Where is if the vomiting started after the pain, then in acute abdomen pictures? More likely, this is about everything. But it's kind of common trend on if the vomiting has started shortly after the pain and it's light in color. It's likely to contain like digestive juices and bile on their four is likely to either be due to gastritis or like obstruction problem or biliary problem. Okay, any jaundice. So this ascertained any kind of hepatic problems with the bile ducts with the pancreas. Um, is what any recent travel IV drug use a needle sharing guys? What is that for hepatitis? Exactly So recent travel would be the hepatitis A. If your IV drug. Use a needle sharing. These are common risk factors and blood transfused covers out of hepatitis B and C. Um, and someone just asked about the vomiting is Pain Association. If the vomiting started before the abdominal pain, then the acute problem the root causes that's likely to be the abdomen itself might be something else happening. Whereas if the vomiting after the pain than the abdominal pain or whatever is causing it has triggered the nausea and vomiting, most likely have you been vaccinated, Vaccinated against hepatitis. This can help you get the hepatitis history as well ads or into a system review the main things you want to focus on in epigastric pain history. Firstly, is John this and Pruitt Pruritis Um, as this can tell you that the Ruben status, if they've got any obstructive causes of their bile duct, any hepatic problems basically or gallbladder problems. This can be followed up with the state of their stool and urine. If somebody has pale stools and dark urine, this is an indicator of obstructive jaundice where the bottle is not getting to the gut, and therefore you're not getting the your billing of the your ability Oh, gin and their stools and is being excreted in the urine instead. So they get pale. So the dark urine, if they got easy bruising and you look, you cut them lots of bruising. And or they say they tend to bruise really easily. This is an indicator off either not enough platelet production by the liver because you to liver disease or they got like a coagulopathy is well on abdomen, ankle swelling again, indicative of liver failure, ascites and things a fever would be indicative of like acute viral hepatitis. You could be, or any other infected causes that you'd be worried about. My gastroenteritis. Get more hepatitis that you could be worried about. In this case, bread flag symptoms you have to screen for in this history includes unexplained weight loss, which again could be more malignant cause G I bleeds. So if they have Molina or the complaint, hematemesis definitely pick up on that anemia. Have there been feeling more tired recently? That's definitely something should pick up on no tunnel symptoms again. Kind of a malignancy picture. And if they're old fifties, well, that's important. Bath medical history. The main things you want to screen for history of liver disease and stomach ulcers. Like we mentioned earlier acid reflux on do I'll call abuse. All these things will help you paint a picture off whether they might have a liver problem or a gastric problem going on in terms of drug history like we mentioned last time is well and said, anticoagulants, steroids, bisphosphonate all of them can irritate the mucosa in your gut, predispose you to bleed and pain. PPI cover is indicative off AH, previous issue of dyspepsia, or peptic ulcer disease, um, on by drugs like paracetamol, amiodarone, methotrexate and antiepleptics. Actually unknown to cause liver problems like liver, fibrosis and things on their known toe. Have effects on your cytochrome enzymes in your liver on Bear four. In tract with other drugs and cause liver problems. You want to screen for the use of those medications as well. That was the epigastric pain. How is your history? Differ when you're doing his room Lower abdominal pain. So the way differs mainly is like your screening. More for bowel symptoms with lower abdomen pain. So you want to spend more time talking about their stools in their usual bowel habits. so, um will be different this time. I will be what, in all about movements. Like how many per day is normal for you. You have to realize that like for some people, going through times a week is normal. Where for some people, that's very little. So you kind of have to go off what's normal for them. Have you noticed a change in your still? The frequency do go more often. Is it diarrhea? Is that odor? Is it dark? Is it pale eyes? Any fresh blood in it? How do you feel when you pass? Is to Are you straining? Um, and this passing stools relieve this abdominal pain that you have. Um, have you felt constipated? Um, Andi, do you feel the increased urgency? You in it? Why my screening for increased urgency to urinate in the lower abdomen Pain history UTI is exactly so. If somebody has got a UTI, then you have a very typical symptom. Is the increased urgency to urinate so that you screen for that as well? A systems review very similar to the last one. Except you would have to make sure you take a sexual history in lower abdomen pain. Usually it's given how much time you have. You would do a sexual history for any abdominal presentation, but especially for lower abdominal pain. Remember to ask about their sexual habits. So ask about sexual partners. Ask about recent sexual activities. Ask about any problems that period recently, their menstrual cycle. If they've noticed any abnormal discharge or bleeding coming out, I'm very important to ask about and the general red flags we talked about earlier as well. Uh, in terms of past medical history this time around talk about previous child births. A swell as that helps that stay. There is a trick history bowel problems from before any recent trauma that could be affecting their bowel now causing pain in terms of drug history. You want to ask about immunosuppressants? Um, as this can cause opportunistic infections on day because after pain, why would I be asking about a long antibiotic course, Guys C diff, Yeah, yeah, although I know it's see if the primary presentation is like diarrhea abdominal very common. And then if we just ask about that in case it's an effective cause on why we ask about opiates. Constipation? Yes, so opiates them wanted you to remember all the time is okay. Scan cause constipation really easily and just screen for if somebody has been taking that and that feels constipated. Okay, So how do you investigate these? The's problems, right? So, again, any acute abdominal pain. What the bedside investigations you want to do? Apart from basic labs on do A B. C D. Would be going to do bedside. Um, dipstick? Yep. Perfect. The director exam. Yeah. Outpatient yet would be your abdominal exam yet? Pregnancy test. Perfect. Price is really good. Um, yeah. Spots on guys again. You're always in the c. G know. Out of water. Scenario is, if it's an acute presentation, you will. You should do the city. It's just part of general acute ops. Um, you would do And easy G uh, you would do. Um um dip A urine dip would look for things like pregnancy. If you suspect they may have DKA. It's causing abdominal pain. Funky tones. There you could find blood that potentially if you think you might have a UTI, you're definitely looking for rays. Nitrites leukocytes in the urine dip, abdomen examination. You can ascertain what kind of pain it is that they have guarding where the pain is, how tender it is. Any signs of about omega least little megaly things like that Blood glucose again for DKA A, um, again, It's just a very general, like acute indicator. Uh, pregnancy test. Definitely. Do a pregnancy test. Women, Because it's from you should always screen for the abdominal pain. Okay. The bloods, um, you know, so you do. Foot back helps on D. Um, acute packet tightest. What am I looking for? A full blood count. I acute pancreatitis filled that out in a full blood counts. What? What sells? Yeah. You could like you to get leukocytosis. Exactly. Yeah. So it in. In the case of that, your abdominal pain station. You do in effort, blood count. Look for, firstly, anemia. Because if somebody has a low hemoglobin off something, it could be due to a malabsorption because of some kind of disease. They have an IBD or something, because it be could be anemic. They have an infection. You don't look raised Local sites. If they have liver disease, you could see low platelets. Um, yes. There's some common things you look for. The next thing is LFTs. So if you suspect, take that palaver problem. You mean you always the left is a little pain just to make sure on testing liver function. Um, using these, um you're looking for, um, basically, if you think that might be a key I going on as well. Uh, you want a certain in the urine creatinine in on diffuse looking at something like DKA. You look at the electrolytes. Um, Andi Yeah, and ABG as well again. Acute situation. It's always helps it in a BG, especially because ABG gives you lactate as well. If somebody has a skin here somewhere ischemic bowel or something, this could cause or any kind of condition that may cause I broke a fusion, this would give you a raise lactate really important to look for that. A break it in protruding decatur crp acute found two marker again really important. Especially things like acute pancreatitis on do, um Ah, on my lap titers because it's an acute inflammatory marker. Doesn't do that. Clotting profile gives your idea of how the liver's doing. For example, for thrombin, time is very important as an acute liver marker. Again, like we said earlier, always do a group and save and that cultures to one in case they bleed. And you need to give them blood on to. If there's an infection going on you and your blood cultures to know what's called infection. It is in terms of imaging, a special tests again. Abdominal acute abdomen, always a direct chest X ray to look for any air in the in the abdomen cavity. Okay, So acute pancreatitis. What are the special blood tests you looking for? What you gonna do for blood? If you expect a few package itis, we're looking for three things. Um, malaise, like, pays One more thing. One more thing. It is in clotting screen. No, uh, nation getting to that. I'm getting to this very thing. Um, calcium. Yeah. Perfect. Yeah. Great. Um, so you would have to do, um, a lease like basic calcium. Typically an acute pancreatitis, amylase and lipase would be three times. Um, the normal numbers on that is kind of indicative off this picture on. Do you get someone? Tell me why you do see him. Calcium. Why would you do it? There's hypocalcemia. Yeah. So pericarditis can cause hypercalcemia and the other way around is while hyper calcium can cause pancreatitis. Um, you could get the both of those things in terms of indicating severity. You will calculate a modified Glasgow score that helps you a sustained how severe the packet itis is. And this will take into account a lot of your blood readings and your ARBs on. Do you can look this up later, but it is a score used to calculate the severity of hepatitis. Okay, great imaging. In special tests you would do consider a lab moment, CT, abdomen, pelvis, and you'll see kind of enlarged pancreatitis. Pancreas, pancreas, parent comma due to inflammation. On day, you'll see a hypoechoic tissue on ultrasound off the pancreas. And you can also be able to see Goldstone's of any around the area. So Okay, what about Goldstone disease? Um, what blood are we looking for? There. Sorry. Not bloods medications. Really, Ruben? Yeah, exactly. It's the LFTs. Um, so in terms of Billy Rubin, can what kinds of, um is sa is their father spits off. Really? Reuben, that can tell you where. What what kind of what kind of where the Goldstone is. Indirect. Indirect. Yeah. So if the Goldstone is in your common bile duct that's going to give you more obstructive pictures. You'll have, ah, higher conjugated Billy Rubin because the conjugated bilirubins were unable to make it to the bile duct in terms of in imaging your abdominal ultrasound to look for gold stones. And if you think there's an obstruction in the common bile duct, which is called Cold Colegio, the CIS, you would consider doing an MRI C P, which is a magnetic residence. Cold pack out garvey. So I turned it off. Um, okay, terms of viral hepatitis. You want to do a non rays of liver screen that screens for a lot of things. So you do a liver sorority screen for different types of virus serology alter things a chemical Tosis on. But there's a whole range of things, but not on a little screen screening. Everything. Basically, um, in terms of imaging provides hepatitis. What would you do? Yeah, you could. You understand, yet perfect you to understand. First exactly. On you see an inflamed liver basically enlarged, potentially acutely Onda. You would consider a liver biopsy if their signs of like complicated viral hepatitis are there like a certain list of indications for this Unlikely to come up in your ski, but I've put it there in case you wanna look it up later. Okay, on, then. Appendicitis. So, in appendicitis, you want to calculate what's called the Alvarado School the abiraterone score again, we'll ascertain the likelihood of this being appendicitis. Um, on do it again. It's kind of like the modified last goes goes just scoring system and takes into account the bloods and stuff. Um, and the investigation to do is a CT abdomen on ultrasound as well, which helps diagnose it. Does anybody know what the classic ultrasound Sinus for pen decide is what it's called Bagel? Yeah, there's another word for that usually use of bagels, I think. I think we're thinking about the same thing. We call it the target sign. It looks like a target. Like little like a doughnut bagel. Yeah, perfect. That's what you might see. You understand? Um, great bowel obstruction again. First thing you do is abdominal X ray. You can look for dilated bowel on. You can ascertain with a small bowel or large bowel obstruction, but CT is definitive. Diagnosis off balance, traction, fab. Let's move. Teo management so acute pancreatitis in terms of conservative management, Nice guidelines say you have to give them some kind of in terrible feeding within 72 hours. There's no real big science behind. This is kind of just kind of giving them nutrition, because if they have a coupon Chinese and they aren't eating, they're not gonna fair. Very well, just cause if they're not eating or have nutrition to keep them going and fight the infection. So, um, it's important that entirely vision started within 72 hours. In terms of medical, the main first thing you have to back it is fluid recitation to give them fluids. Okay, Um, when you do that blood and you look at the hematocrit, if the hematocrit it's is if there is deranged, then that tells you that you're not appropriately processed in them, you know fluid, and you have to give them more. Okay, um, analgesia. Consider IV open opioids to putting. And how about the pain is and antibiotics. If you think there's ah, it's bad enough that pancreatic necrosis is happening. Uh, in terms of surgical management of pancreatitis, you could do an ercp. If there's concern. Collagen tissue on the call. Suspect me is well, if there is, call this the aces that's happening. There's the pneumonic Let's pancreas. That kind of sums up the management of acute pancreatitis, but you can look at your own time. Then look at the management of acute viral hepatitis A. I'm looking at this because there's a lot of conservative things in a few biolab. A tightness? A. So, firstly, because it's a liver problem. You want them to avoid alcohol consumption acutely right, because I could exacerbate it. Make it worse. It's an infectious disease spread by the fecal or a root. Remember that, which means that it's very contagious. So you want to basically of what I asked them to avoid going to public spaces, especially work schooled of nurseries for until the note of infectious on. In theory, this is about seven days of the sort of their jaundice of the start of the symptoms. Uh, you wanna make them avoid going to the place they don't spread the infection. Take steps to minimize risk of transmission. Two partners contacts just a home so like hand washing aggressively are not using the same country. Maybe it's a separate bathrooms of possible Just just being trying to be has hygienic a possible to prevent the spread of this virus on. You could also consider referral to a Geritol you know, retaining or drug rehab center if you think it's indicated with a history in terms of medical management. Acute viral hepatitis A is stuff resolving usually so there's no like antiviral drugs. It's mostly just symptom management of the pain of them. Analgesia, paracetamol can can can consider opioids anti emetic drugs. Onda for the pruritis is well, you can consider to offend me. Yeah, the main thing you have to do is because it's contagious disease. You have to notice the, uh, H B U, which is the, um, the health protection unit that little form on. Tell them that you know you have this, that your patient has this this this contagious infection into the other to their public health records. And because it's a viral infection, you want to follow up on them at least every once or two weeks and consider a full transportation is if you think it's bad enough. Great. Um, so, um, I do another short break for another two minutes. Onda so come back at 2029 and move on to change. About habit, great ignites and brain juice. Uh, we're almost there. Were more than half way through in terms of content. Just bear with me. This is good stuff. I think. So we have. Ms Romanoff. It's a 45 year old woman presenting with change in bowel habit. How are we going to approach her? Let's do some more spot diagnoses. So first we have a 65 year old woman, man. It's very old man, presenting with constipation and bouts of overflow diarrhea. He's noticed streaks of blood nystatin. He also complains of colicky right, lower quadrant abdominal pain. He his wife has noticed that is closed for 10 more loosely recently. Yeah, that's correct. A Kansas stool impaction. Yeah, perfect. Well done, guys. This man has colorectal cancer, uh, most likely given his age, given the election weight loss, given the change in bowel habit on do the blood in the stool. Um, and you can get stool impaction because the carcinoma is blocking the silver in passing. Great. 28 year old man presents his GP with two weeks of diarrhea and right lower quadrant pain for three weeks. He says he's recently noticed red patches on his legs. He has a 12 pack Your smoking history IBD Flare up. Yeah, groans. Any any ideas? Okay. Yeah. Solid. You guys are really good ones. Disease indicated by the diarrhea. That's very common presentation of Crone's water. Diarrhea. Right. Lower quadrant pain. Save your firing. The terminal ileum area, which is where causes these most likely manifests red patches, indicators or erythema nodosa. And smoking is a risk factor and exacerbating factor of those disease. Good stuff. 77 year old woman who is being treated palliatively for late stage metastatic or very in cancer at a hospice has not opened her bowels in six days. Her spiritually eight is nine. What's happening? Opioid over those toxicity, obstruction, constipation? Yeah, bowel obstruction. Okay. Yeah, it makes back there. The answer is you're right. It does have opioid toxicity or off your opioid use because I think the key here is that she's being treated palliatively where patients are likely given morphine for pain relief for the cancer. Onda opioids do do two main things. One obviously to help pain. But second is that can cause constipation that we discussed earlier on can cause respiratory depression. That's why I respect your weight is not good stuff. 36 year old woman presents our GP Complaining off five weeks of diarrhea, she says her stools float. She's been noticing, feeling bloated and tired. She's also noticed a tingling sensation on her fingertips. I BS okay. Any other ideas, guys? Seattle area. Bloated, tired, tingling sensation. Celiac. So, yeah, spot on celiac. See, Let's because I get diarrhea. You get steatorrhea very commonly with celiacs. You get like the other abdominal symptoms like bloating, and you get my labs option symptoms as a result of not absorbing your vitamins. So if she's got a glob in enough iron, she might be. And if you she might get in divisions. Anemia on D is not absorbing calcium. She might get perfect. You're pretty so tingling sensation in Texas, and this is because, see, like most commonly affects the small bowel and duodenum. Good stuff. Okay, so that's not what's, um, differentials and how you can differentiate them in osteo station. So IBD you have caused these all surgical itis. How were they different? So with chords disease, the primary presentation is watery diarrhea and most commonly, right floor quadrant abdominal pain. So, um, you can differentiate this from all surgical Isis because also the crisis you get bloody diarrhea and because it most common because it affects direct him on the colon, is most likely to be left lower quadrant pain. That's the primary differentiating factors in causes. Easy all to get things like weight loss. You get extra intestinal manifestations, like at this Ulster's of range of other things, like gold stones and things, but also just generally poor nutritional status, you two mile absorption disease and the other two colitis. You get a lot of bowel symptoms, so this increased urgency to pool, um, as well as painful defecation. Onda, uh, yet the urge to go all the time. Colorectal cancer. You get a red flag symptoms that we saw earlier. So wait, Lantus pen weight loss, loss of appetite. You might get streaks of blood mixed in the stool. Change in bowel habits. Change in bowel habits like like we saw on the previous thing. You can get constipation and diarrhea at the same time, which can be completely confusing, but this is called overflow diarrhea where you have stool impaction because of the obstruction. But, um, thought that's being digested higher up in the gut is still trying to make its way through. The obstruction is going to trigger past all the stool, and so you get the constipation and diarrhea at the same time. That makes sense. Diverticulitis Tech like typically, you haven't all the patient here and again, it's a little more likely in the colon. So left lower quadrant pain. Low grade fever because technically, it is in fact, of cause usually on and came in terms of changing bowel habit. It could either be constipation or diarrhea. Mixed bag more commonly constipation, though, and potentially a particle mask in the left colon quadrant as well. In terms off, celiac disease gets steatorrhea or watery diarrhea could be either one. Get weight loss commonly bloating, abdominal discomfort, particularly after meals. Anemia. Putem I'll absorption like we talked about like have a neuropathy due to calcium malabsorption as well on general weakness. Really other differentials for change in bowel habits. I Bs Bs again is a diagnosis of exclusion as we know um, thyrotoxicosis ists eyes. A big one is quite important. Differential to mention because it can cause increase urgency, um, to go bowel obstruction. Very important people can be constipated obstipation perianal disease things like hemorrhoids, anal fissures in a rule out gastroenteritis of the specter effective cause of the febrile and things they have recent travel history of eating, eating somewhere dodgy recently could have Gastroenteritis are bloody diarrhea. In fact, the diarrhea drugs like opiates anticholinergics, can cause constipation. And therefore, these are all potential differentials things that can cause change in bowel habit, too commonly. So how do we investigate them again? Um, you want to put down things we do at the bedside for these patients change in bowel habit investigations at the bedside. Did you directly exam yet? Very important. It's doing shots in yet to do acutely abdominal exam. Be a really important anything else. You could do the about side still culture. Exactly. You do a still microscopy culture and sensitivity test eso stool M c and s. You will also do a fecal calprotectin because that's an inflow. That's a sign of inflammation in the bowel that you could do this too. Um, in terms of bloods, you do a B. C's looking signs of anemia. Um, you could do, um, lft is to look for things like, for example, if somebody has infectious diarrhea, somebody has bloody diarrhea. They could have things like, I don't know, potentially humanize, agree, like syndrome where they can equal I You could pick up on their stools, and then they might have jaundice with this. That could show up in the left. He's, um he's a lefty. Sorry. Using these, why would you do use these? This is really neat, actually, a thing like great for your knees. A liver, liver. Mets is, well, really important. Liver Mets. Sorry. Definitely. Lft cyclical liver mets. Uh, they could be diarrhea yet the area lost electrolytes. Electoral imbalances. Really big with diarrhea. Remember that. I'm also looking for, um Well, see, look for looking for urea. That could be a sign all that the suspect they have a a k are if they have humana degree like syndrome that could have an ache. I that could show up with your creatinine urea gap. Electrolytes is a big wad. Especially sodium, dehydrated, especially diarrhea. The sodium is gonna be through the roof. Um, yeah, Onda a big your VBG Tussin, but gas lactate. Um, Onda TFT s took for thyroid thyrotoxicosis all hypothyroidism that could be causing mild problems. A swell on colorectal cancer. You want to do things like iron studies on all to use a test for tumor markers. So see, a is the colorectal cancer to your marker to look for? Um, yeah, potentially indicator of correction. Cancer. Uh, great on D. Okay. And it tells the imaging anybody was suspected core it'll cancer gets colonoscopy or full colonoscopy to look and take biopsies from. And you stayed there. Counter using a CT scan CT, thorax, abdomen, pelvis to look for any metastases and just to kind of stage their cancer. Okay, celiac disease. What bloods are we doing for celiac disease and the T tg Perfect. Yeah. Did you iron studies yet? Folate levels, B 12. Yeah, Solid stuff. Anything else is whole cleared in. Really check for bleeding, because that's kind of a breakdown part of looted, but yeah, really good stuff, guys. Okay, so I in studies, this is because see, that disease will affect the absorption of iron. Most likely your duodenum court can cause I'm I'll Absorption can manifest. Is anemia iron deficiency anemia. Iron studies going profile? Um, because it can affect calcium reabsorption the duodenum so can affect calcium level's better, and B 12 folate can affect it even can affect their absorption as well. Celiac serology involves looking for anti TTG antibodies are RG a in specifics on G r g a empty bodies On what? Something really important to acetate Before you do this test are the Dogg test? Yes. You want ensure that the person is not ideal deficient because the TTG antibodies you're looking for are G antibodies. If the person is already in a tree deficient and i g a, then you're gonna get a false negative result for celiac disease. So you want to make sure that they are screened for IGA deficiency and they don't have it. Why would I do a blood film in see neck disease? What am I looking for? Microcytic. Anemia. Um, like seeing you. You You could just saying that from the foot. But count is anything else I'm looking for in the blood. Feel a blood film? Hypersplenism? Yeah. Excellent. So in select disease, you can get hypos, planina, asplenia, and this can manifest as you see these things called How? Well, Julie bodies on a blood film that indicative off if you like these. Yeah, Perfect. So one's mentioned it. Good stuff on. Do you would do a small bowel endoscopy to look for, Um, that inflamed bow well in CD axe. Really good. Okay. And then inflammatory bowel disease like we mentioned are vitamin B 12 and folate. You could get my labs option on, but can someone tell me some malabsorption symptoms of vitamin Beetle for, like, a little bee? 12. How this man has clinically in the patient anemia. Okay, Paris easier? Exactly. You get perfect uropathy and you get anemia as well. Yeah. Great fatigue. Yeah, on s R is a really good indicator off, uh, kind of the extent of how how inflamed it is. Um, so yeah. Yes, I was a good blood test to do is well on these stations. Got abdominal X ray. Um, what kind of science could you see in a normal x ray for IBD? Guys, let pipe colon. Yes, in ulcerative colitis and get let pipe colon and just cobblestone pattern. Well, that's more on CT scan, but abdomen X ray sometimes, if the colon is inflamed enough. You can get from printing patterns as well on the X ray. Not sure Communists is, but you can see it on. They definitely will get a colonoscopy or sigmoidoscopy because you see a swell and then diverticulitis. Uh, diverticulitis. Um, it's definitely to do blood cultures, because if there's an effective cause, you need to know what it is. I need to figure it out. CRP is a really good indicator for that particular itis. So if somebody presents with left lower quadrant pain, um, has a brace CRP on do is a for you and is vomiting. Then there's a good chance that they have, um, diverticulitis. Great. And for these people, you do another test X ray as well. Just asked a no perforation things like that really important. And also do a ct, abdomen and pelvis to show. Great. So management off some of these in fact, uh, conditions or celiac disease? As you can imagine, it's kind of cause because of hypersensitivity to glide in, which is a breakdown of gluten. They're sensitive to it, so they kind of have to be a lifelong, gluten free diet up state of things that continue to like we try. Barley's felt. They can eat things like rice and potatoes and billets instead. Some patients have secondary lactase deficiency that might be temporarily lactose intolerant. Many things is to recover from this. The time frame is variable, and therefore they have to kind of avoid milk products that period of time on, Definitely look for vitamin deficiencies and kind of supplement them with those in terms of medical management. Really, like there's no drug to give them. It's kind of absence from gluten, but they do need a pneumococcal vaccine because of the asplenia. So, individuals in general, for any disease who develop high post lean, your asplenia need to have the pneumococcal vaccine plus a boost every five years on. Also on a case by case basis, you can consider them for influenza vaccine Can see like like alcohol. Yeah, you could have gluten free beers. Yeah, you do it exactly. You need to make sure it's gluten free. Yeah, exactly. Okay, All surgical itis. So, in terms of conservative management again, it can cause malabsorption problems. Right? So, um, you need to make sure you supplement them with enough nutritional supplements. that eating rights on do. Also, there's a risk of developing a malignancy in IBD and therefore you need based on the severity of their disease. My guidelines kind of have, um how long after that diagnosis of IBD they should be screened with the color lots to be for colorectal cancer. Um, so this is like on a case by case basis on D is very specific. So But you just need to know about They should be referred for a colonoscopy at some point, um, to screen them for the court to cancer, all surgical I just in terms of support of care you want to. You want to help with their symptoms, right? So lot of them have diarrhea. So antidiarrheal agents like Loperamide, it's anticholinergic to relieve cramping. But don't give these an acute scenarios because the's can just make problems worse that you suspect perforation or things like that don't give these things that might make it worse. Avoid and says it opioids and add little logic because, as you know they can. They can interact with the bowel movements and the mucosa and make things worse when you're inducing remission. All surgical itis, usually recommend topical rectal aminosalicylate. It's like muscle a zine off sulfasalazine, and if it's more severe, you can add on a high dose or a low drug as well. So in, if it's bad enough, you're also tickle itis. Surgery can be curative. It can be curative and also declined. This on you basically like, um, um, consider doing a proctor colectomy, which is removing the rectum and the bits of that hole there and their colon as well. Um, this can first see cure the UC and older. Reduce the colorectal carcinoma Risk. If somebody presents with severe acute colitis in hospital acute Really bad flare, then the first line treatment for that is IV steroids. If they don't improve in 72 hours, give consider giving them IV cyclosporin, and if they still don't improve, then consider surgery and remove the erection. And that colon, Um, and give them ah stoma bag basically off the surgery. So if the current disease, in terms of conservative management like we said, smoking can make it worse than smoking, is a risk factor of current disease, Therefore, further smoking cessation maybe suggest smoking cessation support groups as well make sure they're getting all the nutrients. Give them vitamin supplements to refer them to dietitians because there's a risk of osteoporosis. It's osteoporosis. Associate with corns disease Screen for that, with the dexa scan avoid and said as it can exacerbate the disease. On also again is the risk of malignancies. Green recorder, actual camera up supportive therapy is very similar to UCS analgesia antidiarrheals on ball, so things like stress and depression can make it worse, exacerbate it and cause flares, and therefore you can revert them for management. This well in terms of medical management and using remission in Crone's is done with blue corticoid um, prednisolone. And you can add on a thyroid period of infliximab, depending on severity of disease. And if the disease restricted of the parent and area on not anywhere else about, you can just give the medicine itself. Yeah, surgery as a poster crone's as opposed to two. Crisis is not curative, Um, because these can come back and therefore, if you did, surgery and formula Crone's would be for acute management because it's really unmanageable and it's really inflamed, and it's causing them lots of symptoms, and it's very acute, but it does not mean that it kills them off. The cure is disease. So this would be is involved Surgical resection off part of the colon that are acutely inflamed. Fab. Really good. That was about changing bowel habits. Thank you. Sick You're on, guys Might move on to jaundice. Now I think I found for a bake. So what? We're going to John this So we have a lady for viral lady who presenting with jaundice Onda Susan Spot diagnoses. So we have a 40 year old lady presenting with jaundice. She complains off severe right up According pain that started about six hours ago. She describes having colicky pain over the last week. She has a temperature of 40 degrees c on is mildly hypertensive. What is the most likely diagnosis guys Ascending colon giant issue perfect. So firstly is colicky pain in the right upper quadrant That's telling you, you live on the gold bladder. Um, and the fact that she's bad broil, maybe pointed infective causes well looking at ascending colon giant. It's really good. Um, next 1 57 year old woman presents his GP with John Dis. He says he feels nauseous on as a temperature he's bus driver and consumes regularly. Regular consumes 45 cans of beer a day with heavier drinking over weekends. Examination revealed about a megaly with mild tenderness over the right upper quadrant. Alcoholic hepatitis? Yes, perfect. So you get alcoholic liver disease and this person with this heavy alcohol intake His John Dis um, about two Maglie due to the Hib at cellular inflammation and the Stiolto hepatitis that's developed as a results off the alcoholic hepatitis 25 year old man presents with jaundiced and right upper quadrant pain. He noticed in a really, really, really with this everything with this rash on his arms yesterday and there that he's febrile When he checked his temperature on further questioning, he states that a year cable in Jack's heroin intravenously What were you thinking here? Hepatitis. What kind of hepatitis are we looking at? Hepatitis B? Yeah. Yeah. Attention. E c is well, because of the IV drug use. Um on d? Yeah, we did get on. Do we have a 75 year old man presenting to GP with diarrhea? And John this his partner has noticed that he's lost quite a bit of weight and that he seems tired all the time. He has 25. Pack your history of smoking and his history of heavy alcohol intake. It patricide Acosta Noma as you to mean, uh, he's actually got jaundice. So this would be head of pancreas head of pancreas cancer had a bank react ahead of pancreas pancreatic cancer. And it's causing an obstructive john despicable because it's blocking the ampule of batter where bile enters the gut and therefore so letting bile enter, causing obstructive bile buildup in the bile duct, causing jaundice. Okay, lovely stuff. So in terms of jaundiced, when you're thinking of John Desk, John Doe's could Feet do 23 possible causes, right? It could either be a prehepatic cause some intrahepatic cause within the liver or something, and obstructive cause that's happening after the liver. So in terms of prehepatic causes, it's either due to an overproduction of Billy Rubin, usually due to, ah, high turnover ridge of red blood cells or excessive hemolysis. And this is causing an increased unconjugated Billy Rubin, and that's gonna cause jaundice conditions that can cause prehepatic jaundice. Do you take excessive hemolysis are things like G six PD deficiency transfusion reactions, sickle cell anemia. Fallacy me A. Things like that. Intrahepatic causes are usually due to either damage to the hepatocyte themselves. There's this problem in re uptake off the Billy Rubin. Or there's some kinds of obstacle within the liver that's causing cold status. Intrahepatic obstruction Okay, problems that can cause this are Gilbert syndrome. Um, can someone tell me we give? But syndrome is Gilbert syndrome deficiency and conjugating enzyme? Exactly. So the enzyme that's used three UDP enzyme that's used to congregate unconscionably Ruben to conjugated bilirubin is deficient in some people. Definitely get a build up uncomplicated, get Billy Rubin and therefore get jaundiced. And this is Gilbert syndrome. File appetite is I called hepatitis. All of these problems can cause intrahepatic on this posthepatic John. This is because you haven't obstruction after the liver after the conjugated bile has left of liver. There's something that's stopping it, usually a goldstone or pancreatic cancer that's stopping it from draining into the gut. Let's talk about examples of these and how they may present differently in the history. So if we take a handwritten intrahepatic cause like alcoholic hepatitis and compare it to a post hepatic cause like Goldstone's colelithiasis. How do they present differently? We know they both present with jaundice and alcoholic hepatitis. You might comment to get up out of megaly. This is because of the accident inflammation like a doctor about earlier, and stay out of hepatitis that causes, like the liver to kind of regenerate a little bit of itself because it's it is losing function. This happens before cirrhosis. This is before the whole fibrosis stage. Um, you could get tenderness over the hepatic area, Um, whereas in Call it the ASIS, you get biliary typical colicky pain that comes and goes especially worse after meals after eating, because that's when bile is kind of secreted. You get nausea in both but alcoholic hepatitis. You might get a further lot of appetite and weight loss and a low grade for you with tachycardia don't necessarily get with recall. Is the ASIS it all? And in terms of typical risk factors, you could look for inpatient demographic. People with alcoholic hepatitis will most likely have. Will will have persistent long term history of alcohol abuse. Um, where is it cold with the ASIS that there's this pneumonic the six F's to remember the risk factors for scoliosis of fact. Female, fertile like pregnant 40 so 40 years old. Fair skin to Caucasians, Onda family history, Colds does them A lot of the types of hepatitis I've summed up This is from knishes slides Last, you did a really good job of making really comprehensive table A different as hepatitis I've adapted it, drew, like I've removed some of some stuff and Addison stuff on the main thing. You should know. The main thing I will say to take away from this table is that hepatitis A is fecal oral in on. In order to have hepatitis C, you have to hepatitis A. They're linked. They're both figure or, uh, the other types of hepatitises are all body fluids and infected blood transmission. Recent shady travel history is usually hepatitis A or hepatitis C E. Uh, this is used to travel or eating dodgy foods. And if somebody has had IV drug use, um, like or multiple sexual partners Men who have sex with men tattooing the tattoo needles Ah, blood transfusion of the risk factors for hepatitis B and C, uh, important to know that hepatitis a zar cute acute disease itself resolves acutely or his hepatitis B and C can become chronic. Problems with your liver is well, also note. Hepatitis B and C can predispose you to hit him back to Simula carcinoma as well. On the other thing to note is that in women in pregnant women, hepatitis C can be fatal. Has a higher mortality rate is, well, impact of women. Okay, so when you're taking it used to from somebody with John this, what do you try to elicit? Firstly, when did the joint starts? Sorry, actually, first I took about a judge. Can anybody tell me the chat? Why? Um, age is really important, especially John was history like what is a young person? Was his own older person tell you it's a young person? What could you protect? You look for just based on stereotypes. Hepatitis. Why less likely to have liver damage? More likely Infection? Yeah, IV D'You Exactly. Yeah, Perfect guys. So more likely to have wrist taking behavior. So more erratic sexual activity. More sexual partners more likely to be involved with tattooing? Are the drug use things like that? Obviously, the generalizations, but it's just kind of trend. You see, um, if they're older, more likely to be on a malignant cause, like pancreatic cancer or particulate carcinoma. Um, yeah, great on that of John. This, um So, like we said, if it's an acute cause, like acute viral hepatitis, you get the job. Disquiet quickly within one or two weeks. What if somebody develops? John is chronically. What can I tell you? What if they have, like, one month slowly worsening or two months lowly? Worse than his your joint. This basically poisons more long term problem, right? So if they have, like a malignant problem or an inflammatory problem that kind of takes time to develop, that would be more of a longer onset. Yeah, Okay, cool. And even hepatitis B, C and D are chronic problems as well. Not acute like that. Point that as well, Great. And become the liver disease takes a long time to show up, so someone could have really bad liver, not know it until until it's really late. And it's really bad change in your in. What kind of change would you see in your and sometimes people on jaundice? And why change in urine? What, get some people complain off dark urine due to congregate. A bilirubin document? Exactly. Yeah, perfect. Basically, if you're obstructed, jaundiced, all of this bile is not getting to your gut. Okay? It can't be excreted in your feces the and therefore it goes and gets excreted in your urine urine instead. And they're felt in the year and you'll be able to pick up Billy Rubin, get dark urine, okay, and pales stools. Reason in this, in fact, is the hepatitis, uh, hepatitis things and the abdominal pain again helps you ascertain where the pain is. You can get like Murphy's sign. Could someone tell your Murphy Sinus? What is Murphy sign? But it's through the acute cholecystitis. Yeah, yes, you don't usually get jaundiced. Icals to start is, however, because it's do with your bladder. Basically, it's It's an examination thing that initial discussing more detail on Thursday, but it's like you elicit pain on inspiration when you touch the cold better. But this will go into more detail about that. Yeah, shopping in our culture, great swelling gives you history off like liver disease because it gives you ascites and peripheral edema, fatigue and, like things like malignancy can make you tired. Um, recent travel like I said, Hepatitis A um, recent needle sharing blood transfusions could be hepatitis B C, new medication, things like methotrexate's, like on the right hand corner of the screen. Paracetamol, amiodarone, methotrexate, anti epileptics. All of these unknown. Um, probably because when it comes to liver like methotrexate is known to cause liver fibrosis, anti epileptics, an amiodarone interfere with the action of cytochrome people. 50 can cause problems deliver. You also wonder if they're pregnant because you get obstructed, John This, which is the whole topic on its own. Um, great system Review again. Screen for Let It Flags for malignancy. I've been weight loss, job, lead, anemia and older age change in bowel habits. Screen for that as well. Our parietal. It's like itchiness. Easy bruising again indicated of liver problems. Coagulation problem. Because the liver is not producing clotting factors. Fever indicative of infected causes past medical social history. So past liver disease you would look for inherited or two um, you conditions. They're a bunch of bunch of genetic conditions that can cause like impaired reuptake of Billy Rubin into the liver. Like wrote a syndrome or do been Johnson syndrome. These inherited or two immune conditions that acute sclerosing cholangitis, um, which are associated with the ulcerative colitis. The's ultimate conditions. You should screen for previous malignancy because we discussed earlier having cancer. One predispose you to having cancer again. Potentially the risk factor got Why would you ask him about gout? Why would you ask about doubts in jaundice? What has got caused by what is the problem in doubt? You have lots of urea, right? You You work as a crystals. Yeah, exactly. So if you haven't, he more like a lighted cause of your John. This But you have a high red cell turnover or something. You might have high production. Diarrhea that caused out there for this could be associated with it. Um, yeah, that's basically it. Alcohol abuse again. Important for liver disease on diet. So fatty liver disease. Ah, sorry. My bad. You it acid. Did not urea mentioned that wrong Your gas in your area? Um, diet. So if that have a bad diet of the generally quite a beast that you're looking at things like fatty liver disease, potentially on Benny past surgeries as well. Like if you had a cholecystectomy in the past, things like that drug history. We talked about the liver trouble makers. Antibiotics, like quinolones are known to interfere with the liver on can cause diarrhea, like quinolones can cause the range lefties on present with diarrhea as well. Antimalarial drugs sell for drugs. Why we ask you about those? Like, um, one of those queens? The quick chloroquine and stuff self drugs, patches, socks it. How would they do? Well, because Yes, because that triggers for hemolysis so they can cause increased him or listless and give you a human lighting. John, this picture on the the combined or concept of pill, which contains east urgent can also cause liver problems on because John this So that's another risk factor as well. Great. Some quick investigations for this. Almost reaching the end. Guys almost there. Um, forth and beds are investigations you want to do for John Lewis. Anyone who presents with jaundice Abdominal exam yet? There's a rectal exam. Yeah, well, you could Yeah. Ops? Yeah. General labs, for sure. Your analysis. Yeah, sure. Anything else at all? You had also do a stool stool culture as well. Okay. Um, so, basically, obviously anyone present acutely do some basic option them doing formal examination to the clinical signs off on D on da you analysis. So you analysis. You can look you you will see the urine is dark if it's obstructive John this for example. Yeah. Um Onda, um, stool culture. If they have things like Husada is, he will have, um, syndrome You might pick up like on shigella or equalize with that I am. It's infected cause full blood count. You were doing bloods because you looking for so if it's infective cause you could see leukocytosis Yeah, on. But you could also find, um, like I said, low platelets in liver. If they have chronic liver disease, you do liver function tests, which will talk about in a second in detail, definitely to a certain if it's a liver problem, whether it's a problem of the liver or bile duct. Um, using these to look for urea. Uh, look for any signs of achy I, um on. But, um yep, that would be you. That would be good. Coagulation studies again if the liver function to perform in time production. Floating factors look at acute and chronic liver function. So, an example. I've given off a pretty part of cause, which is the amount of him just six pd deficiency, which can cause hemolysis. I've given example here of GI six PD deficiency on the blood you would do here are like, um, blood smear because you look for things like Heinz bodies and bite cells on Not good is because of the sake of time. I'm I just brush past this, but for you to look, look through it later. Um, on D you want to serve him? Whether this is the cause of human. I joined this. I'll call the hepatitis you give them abdominal ultrasound and you'll see enlarged liver with inflammation. Viral hepatitis. You want to look in their blood's for I'm t h a v e r g e m on are you g antibodies M antibody presents The presence of them suggest acute active infection. Those are G antibodies. Either suggests vaccination or they've had a past. In fact, you of the exposures previously. You also do have done ultrasound of these patients as well. On day for colon basis again, you want to do a right accorded percent look for gallstones and if they're again is a problem in the common bile duct, you would maybe do it MRCB. So it's quite like a liver function tests. Okay, this is really hard and really important, because it can really help you narrow down the diagnosis and what you think where the problem is coming from with John this. Okay, so you have different parameters for different kinds of problems. So if we're looking at his heart a cellular dominant damage, we're looking at A S T. And the LD the trans I mean a transfer. His enzymes. Okay, The main difference between them is that a L T. Is liver specific. It's only found in hepatic cellular cytoplasm, whereas a ST is found in the liver, in the heart, in the muscle, your muscles and your red blood cells. But okay, when you're looking at a C A l t values, like, how do you interpret them? What do they mean? You're mainly looking at the ratio. So that ratio of ST to lt Okay, So if there's less ST compared to a lot of that is a lot is raised more. The ratio is less than one. You looking at problems like Uncomplicated vial had borrowed hepatitis very early on minor fatty liver disease or called Stasis that happening somewhere outside the liver. Okay, However, if your ST is raised more than two times, then you're a L. D. Okay, and you're very show is more than two, then you're looking at more but worse causes like alcoholic hepatitis. On the court of hepatitis D E compensated cirrhosis. This is adjusted, but a much higher SD compared to a lady. They both might be raised, but the air see would be raised a lot more than the lt a way to remember which one is, which is like I have a pneumonic, which is when a ST is more than a Latino called hepatitis Think. Make a toast with alcohol because the ST and toast indicates maybe alcoholic hepatitis. That's that's how I remember which one is which. The next indicator of liver function test is hepatic synthesis. This tells you this tells you more about your intrinsically your function, how your liver is like metabolically functioning. In that moment, you can look at albumin. So are human has a 30 day turnover rate between It's not acute indicator, which means that someone has acute liver problem today. It's not gonna show up on the albumin tomorrow or day after, like it's going to take 30 like it was going like a few weeks. Okay, this is more of an indicator off, like chronic liver disease like cirrhosis, uh, malnutrition and things like that. It's commonly elevated due to dehydration, and it's a good indicator off liver function chronically because it's only synthesized by the liver, the body, no ups. You can also completed count platelet count. It's older reduced in liver disease, because if you have interesting liver disease, you know gonna be producing enough trump thrombopoietin to produce enough to induce platelet production. And you have reduced platelets in your blood. This older happens in portal hypertension. At the most important acute marker of liver function is theme. Perform in time, your PT because this has a 24 hour turn over rate, which means if something's wrong is happening to you will be able to see it on your left. He's tomorrow on the PT time. Okay, uh, that's important. Acute mark up. We then move on to markers of cool Stasis where there's like where the bile isn't flowing and this can cause John. Guess right. So the first is alkaline phosphatase. So alkaline phosphatase is again is a non specific marker. Okay, It's an enzyme that's found in many places in the liver, in the boat on the plus center in the kidney. Okay, it could be commonly elevated due to call states. Like we said, infiltrate of diseases like, um, a low doses are off the Paxil, a malignancy also raised in increase osteoblasts activity because it's in the bones and pregnancy because it's little center. Therefore, it's been non specific, and you can't really use it to make a diagnosis. This, however, if you use a low pee in conjunction with this thing called GGT damage et okay, that can help you to gamma digiti is a protein found in the liver, the heart muscle. New the sites. However, it's a very sensitive to bio duct obstruction. If you have a problem in your bile duct and my usual, he's going to be able to pick it up. Pick Lee and fast. Okay, good, clean. Well, so if you have an elevated a lot pee on elevated Dharma gt, uh, this can tell you that you have a problem in your bile duct is obstructive issue in your biliary tree. Okay, on it was likely post hepatic issue, but then we want a baby. Ruben. Uh, the best mark of jaundice, which is, if you're raised really raised. Total. Billy Rubin. This may manifest as a yellow discoloration on your skin in your eyes and you remember it Very routine. However, the test can be split. You can look, I just didn't get him a little him unconscious, gated be Ruben. If you're concerned about like a human lighted cause like too much production, a bilirubin or impaired conjugation Billy Reuben. It's like Gilbert syndrome, for example, or like sickle cell disease or things like that. Or if you're looking at and obstructive cause then you can have a raised conjugated Billy Rubin. Um, like we discussed earlier those the different liver function test. I hope that makes sense and won't use them how to use them. That is the end, guys. Congratulations. The same till the end. Thank you so much. Listening to me. Hope that was helpful