Computer generated transcript

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

Yeah, I think that's us live now. Hello. All right. Hi, everyone. Thanks for joining us today. Um, so we have the next week in our series which is Gastroenterology. Sorry, I think there's a bit of a Echo Monday for me. Possibly. I'm not sure. I don't know who that's coming from, but anyway, sorry. Ignore me. I can't hear an echo fine. Um, so sorry, go back to what I was saying. So, yeah, welcome to the talk. So, today we're um, discussing gastroenterology, there's a lot of different conditions that you do need to know for this cos it incorporates the surgical side and the medical side of things. So we've tried to condense it down to the most high yield areas. Um, and there's just a couple of big topics that we've omitted just because they are covered quite extensively. Um, so let me just quickly share my s slides and then we can get started with things. You up there we go. All right. Um, so just to quickly introduce ourselves. So hopefully you've been to some, some of the previous sessions. So, I mean, at, er, part of the committee for me. So we're doing a final series and various other series as well coming up like f on prep, preparing for, er, S FP interviews as well. Um, um I'm also on FY one also on the med committee. Perfect. Uh So these are just some of the conditions that we'll cover at some point today, but we'll share the slides on medal later. Uh So you can have a closer look. All right. So I think we'll go straight into it. So we've changed the format a little bit. So we'll go question and then answer question and then answer rather than doing all the questions at once, answers later down the line. Um So once everyone's ready, if you have a pen and paper, you have a minute for every question. Um So we'll get started now, right? Well, that very 10, that's so annoying. Ok. So that's been about a minute and then to hear the answer. Um So question one, a 55 year old female patient presents to A&E with nausea, vomiting and a three day history of constipation. She normally opens her bowels every day on examination. She has generalized tenderness and rigidity of her abdomen and no audible bowel sounds. So, what's the most appropriate management plan? Um And the right answer is b which is an urgent laparotomy. So, in this question, um the patients presenting with symptoms that indicate she has bowel obstruction, but the generalized tenderness and rigidity of her abdomen indicate that she's got peritonitis and potentially a perforated bowel. And so that's why urgent laparotomy is the correct answer over like a drip and suck. So, you're more conservative management for a bowel obstruction, um, or an urgent colonoscopy and any of the other answers. Um, next slide, please. Thanks. So, just to go over bowel obstruction, there are two different types. So there's mechanical bowel obstruction, which is what you tend to, um, do optative management on um in surgery. So you've got tumors, adhesions, anything that's physically blocking the movement of food through the gi tract. And then you've also got your functional obstruction also known as ileus. So there's not a physical obstruction there. But for whatever reason, the bowels aren't actually moving food through the gi tract. Um So could be POSTOP ileus could potentially be drug induced. So, with your opiates, they can lead to constipation, could be secondary to diverticulitis, could happen with a um, autonomic neuropathy, et cetera. So, some of the causes of small bowel obstruction are adhesions. That's the most common cause. Um So in a stem, in a question, it may hint to the patient having adhesions if they've had previous surgery on their abdomen may also be secondary to cecal volvulus or a gallstone ileus. Um, and then causes of large bowel obstruction. Uh Generally, tumors could be diverticular disease and it could be sigmoid volvulus, patients generally present with central abdominal pain as well as abdominal distention. Um they often times have vomiting and this would be fent vomiting as well as absolute constipation. So they're not opening their bowels at all, even to pass gas. Um, on examination, it may be a tender abdomen but it is generally still soft. Um, and on auscultation, you tend to hear either no bowel sounds or tingling, bowel sounds. So, for your investigations, obviously, you'd want to do your routine bloods, you also want to get a lactate to check for any sort of bowel ischemia as well as a VBG to make sure that they're not becoming acidotic if you're suspecting that they may have a volvulus. Um, you'd want to do an abdominal X ray, but just for general clinical practice, um, at least in my hospital they are quite fussy about Abdo x-rays. So that's something you might want to keep in mind. Um, but for example, purposes, Abdo x-ray, um, for a small bowel obstruction, you'll see that there's the bowel loops are dilated more than three centimeters. You'll see, um, what's called valvulae contis, which are lines all across the small bowel, which you wouldn't generally see on, um, someone who's got a normal abdomen and an Abdo X ray. But it's because it's dilated that you can actually see those lines and if the patient has cecal volvulus, you may see what's called the embryo sign. So if we just go back a slide, um, it's this second picture where the, if you have a slightly creative imagination. You can think of it as looking like an embryo. It's almost got three parts to it. And that's the sign for cecal volvulus. Um, and then if we could go forward a slide doctor, um, in an Abdo X ray for someone with a large bowel obstruction, um, you'll see that the bowel is dilated more than six centimeters and, um, at the cecum, it can be more than nine centimeters. You'll see the hoster visible. So these are small lines you'll see across the bowel that don't go completely across. And if it's a sigmoid volvulus, you may see what's known as the coffee bean sign on Abdo X ray. So if you go back a slide again, um, this first picture looks like a coffee bean that's got that split in the middle and then the really, the two really large dilated loops of bowel. And I think you can also see the Hatra on there as well. If you go forward a slide. Thank you. Um, and then you may also want to do a Ct Abdel vs with contrast because that will give you a much more detailed picture of the abdomen as a whole. So for your management initially, you want to do the drip and suck. So inserting a large wall g let that drain out any, um, vomit or any substances that are in the bowel, give them IV fluids and keep them nil by mouth. And that's your conservative management. If a patient has sigmoid volvulus, you want to take them for sigmoidoscopy and then decompress with a flatus tube. I think I've got the right tube there at the end. Um, but you'd still want to do your drip and suck technique initially. And then you'd want to take the patient for surgery if drip and suck isn't helping to resolve their obstruction or if the patient has cecal volvulus. So, for a perforation, um, some of the risk factors are a patient who has a bowel obstruction, patients with diverticular disease and patients with malignancy. So you always want to have in the back of your mind. Has this patient perforated. If you're managing someone with small bowel or large bowel obstruction, the presentation, they'll have really severe abdominal pain and tenderness. The abdomen will be really rigid. They'll often be lying on their bed just not moving at all because they're in so much pain and the patient will have absent bowel sounds for the investigations. You really want to make sure you're getting a lactate and a VBG because they may have bowel ischemia. You also wanna do a group and say because these patients will most likely be taken to theater. If they're fit for operation, you'd also want to get an erect chest X ray done immediately because then you'd be looking for free air under the diaphragm. And that's, um, a classic sign that the patient has perforated then management would be urgent referral to general surgery who will take them for a laparotomy? Ok. So now question two, I'll give you a minute for this. Ok. So for question two, a 67 year old man is under investigation by the upper gi surgery team for dysphasia to swallowed foods which has worsened over the past few months. He's now only able to eat soft foods like porridge yogurt. He's also lost three stone and weight over the past few months. What is the most likely finding in this patient's barium swallow? So the right answer is a an apple core stricture. Um So just to quickly go over the other answers, a bird beak appearance um is generally seen in achalasia out pouching on the posterior wall junction between the esophagus and the pharynx. Um is a pharyngeal pouch. Um Patients will, it's unlikely they'll have a normal bar and swallow if they've gotten to the point where they can only eat soft foods and they've also lost weight. Um and patients with a corkscrew esophagus generally have a diffuse esophageal spasms. Um And so the diagnosis here from this apple core stricturing that's seen on bar and swallow is esophageal cancer. The so here are kind of your top di um differentials for an upper gi cause of dysphasia. So, for esophageal cancer, you generally get progressive dysphasia to solids. It doesn't generally progress to liquids unless it's really advanced. It's typically a short history. So over weeks to months. And as an additional symptom, you may also get a um patients presenting with a hoarse voice. If the tumor is compressing on the recurrent laryngeal nerve, and you'll see an apple core sign on a barium swallow which is um kind of the narrowing of the esophagus due to the tumor and pressing. Um and then for achalasia, you get dysplasia to solids and liquids from the very beginning. So that's different to that kind of progressive picture. You see in esophageal cancer patients tend to present with sporadic episodes that respond spontaneously. Um And then you also get a bird beak appearance on barium swallow. So you get like an expanded esophagus and then it suddenly kind of tapers off. Um And if anyone doesn't know achalasia is um what happens when you kind of get, it's like loss of the um innervation to the lower esophageal sphincter by the myenteric plexus. Um In diffuse esophageal spasm, you get intermittent dysphagia and heartburn and you'll see what's called a nutcracker esophagus and esophageal, a barium swallow or corkscrew esophagus. And in a pharyngeal pouch, patients can present with dysphagia and they also present with regurgitation quite classically. So they'll, they may tell you that a few hours after they've eaten, they're noticing they're bringing up like whole bits of foods, like patient had carrots in their dinner and like, oh, I regurgitated. So a bit of carrot into my mouth, you may also see a neck swelling. They may also have halitosis cos obviously, that's food that is kind of sitting in the pharyngeal pouch and you would see it on a Barris swallow and I know that a Barris swallow is a fairly outdated investigation. Um, currently, but it's still quite an exam favorite just in terms of those like classic signs. Ok. So another minute for question three. Ok. So question three, a 40 year old patient presents with coffee ground vomit and Melina on examination, their BP is 70/50 heart rate is 100 and 24. And they also have asterixis. They undergo an endoscopy which successfully stops the bleeding, which medication should they be discharged with to prevent another upper gi bleed. And so the correct answer is a which is propranolol and so the stem is trying to get at the fact that this patient has esophageal varices and the asterixis is the hint that the patient has liver disease. Um and presenting with such kind of being so systemically unwell from an upper gi bleed as well. Um Next slide, please. So causes of an upper gi bleed. It can be caused by viruses that could be esophageal viruses. It could be gastric viruses can be caused by ulcers can be caused by a bleeding tumor. Um and it could also be caused by a mallory wise tear, which is when patients get a small tear in their esophagus because they're vomiting so much Um So in order to risk stratify patients who have presented with an upper gi bleed, you can do the Glasgow Blatchford score and this is trying to identify patients who might be candidates for outpatient management of their upper gi bleed. You can also do the Rockall score, which is trying to identify patients at risk for adverse outcomes as a result of their upper gi bleed, patients present with hematemesis. So this can be fresh red blood or potentially coffee ground vomit, which is um, blood that's been digested and they can also present with Melina, which is that black tar like stool. Um, again, which is from blood that has been digested. So, some of the investigations you'd want to do, you'd want to do a full blood count. You want to pay attention to their hemoglobin. See if that's dropping, you'd want to look at their user knees. Um, patients with an upper gi bleed have a raised urea because again, that's from the breakdown of the red blood cells. You may also want to just do routine bloods like a CRP and you want to check for TS as well as if the patient doesn't have known liver disease or known varices. This could potentially point you um in the right direction, um, as to the cause. And you may also want to do a group and save on these patients because, um, you don't know how severe that bleeding is going to be. So generally, if the patient has viruses, you want to give them IV terlipressin and antibiotics immediately as well along with any sort of fluid recess and doing your at e assessment. If they have known viruses, you also wanna take them for an O GD. And generally you take anybody for an O GD once you've actually controlled the bleeding. So they can actually find out the source if it's a non variceal bleeding or you don't actually know if the patient has varices, you don't want to give PPIs um when, when you're in endoscopy, you can control variceal bleeding by doing band ligation of the varices. Um You can give N Butyl to cyanoacrylate, which is a very long fancy name for something you can inject into the um varices to help stop them bleeding. You can do tips, um which is a trans intrahepatic portosystemic shunt, which you can see on the diagram. It just sort of diverts the blood flow um from the portal vein to the branch of the hepatic vein. Um and that's if your band ligation, um and sclerotherapy doesn't work in endoscopy and then you can also insert a Sangs blake more tube if the patient is having an uncontrolled hemorrhage. So nothing else is working. That's essentially a tube that goes down the nose um into the stomach and it's like a balloon that inflates. So it's essentially just um it's trying to compress the source of the bleeding to stop it if all else fails, um you would want to take them for surgery. So if they've had a failed endoscopic management of their um bleeding. So for prophylaxis, for variceal bleeds, you can give propranolol, but this is only in the case of like known varices. OK. So another minute for question four. OK. So question four, a 30 year old woman returns to a clinic after receiving hepatitis B serology test. Her results are as follows. So um Hep B surface antigen is positive antibodies to the surface antigen are negative and HB E antigen is positive anti HBC IgM which is antibodies to the hepatitis B core antigen are negative in terms of the IgM but positive for the IgG. So what's her Hepatitis B status? So this shows that she's an active chronic Hepatitis B um carrier. So she's got an infection which is chronic. Um So the next slide, it, this chart quite nicely goes over hepatitis B serology, which is something that I find quite difficult in medical school. So your surface antigen denotes if the patient has a current Hepatitis B infection and this includes acute or chronic your core antigens um are a marker of some level of Hepatitis B infection. So I GM represents an acute infection and then I GG represents a chronic infection. Antibodies to your surface antigen indicate that the patient has some level of immunity, whether this is from um vaccination or from a previous infection. Your hepatitis be antigen is a marker of infectivity, an active activity of disease. And so, anti HB E antigen is detected in people who are chronically infected or patients who have actually cleared an infection. So if we just kind of go back to the question just to go over some of the answers. So this patient has a positive surface antigen. So she's got an infection at the moment, negative um anti H BS. So she's not cleared the infection and she's not been vaccinated. Her HB E is positive. So this is an active infection that she could pass on to somebody else. Her I GM is negative indicating that it's not likely to be an acute infection and her I GG is positive. So that's likely to be an active chronic infection for an acute Hepatitis B infection. You likely see positive surface antigen. You may have an er positive HB E and you'd have a positive IgM if the patient is a Hepatitis B carrier with an active infection, um you would have hepatitis be antigen is positive but um and maybe the surface antigen would be positive as well but not a positive I GG immunity following vaccination will have everything being negative apart from the anti H BS and then immunity following an infection will, you'll have a positive core antigen, negative surface antigen with a positive um anti H BS. Um OK. I hope that covers that. Um And if anyone has any questions, feel free to like pop them in the chat or um just kind of interrupt the session. Um So next question. OK. So question five, a 50 year old woman presents with abdominal distention on a background of chronic alcohol excess. On examination. Her abdomen is soft and nontender. It's dull percuss and has a positive fluid thrill. She has an acidic tap done which shows the following results. So she's got 40 red blood cells per microliter, 100 and 70 white cells per microliter two neutrophils per microliter protein is three LDH is 100 and 95 and her serum albumin is 30. So the most appropriate management plan for this patient is spironolactone and a sodium restricted diet. And that is because so this patient from these results, the white cell count is less than 225 or 250 off the top of my head. I can't remember which one, but that's what indicates spontaneous bacterial peritonitis or some level of infection. If your neutrophils are high. Um that indicates it's SBP if your leucocytes are high, it could be uh TB ascites. But I think that's quite advanced. So I'd just forget about that. Um And because she doesn't have an active infection, um she just needs diuretics to actually get rid of the fluid as well as a sodium restricted diet to prevent it from coming back. So IV cefotaxime is what you would give for active S BPA large volume paracentesis would be for 10 societies, but her abdomen is soft. Um There's no indication that she actually has tense societies. So it's better to just go with your medical management for trying to get rid of it. She does have a need for acute intervention as you don't want the ascites to sit there and for her to then go on to develop SBP and then oral Cipro is your prophylaxis for patients who um may develop SBP. So just to go over ascites. So as with any sort of effusion, it could be transudative or it could be exudative. Um if your serum albumin ascites gradients more than 11. So this is taking your serum albumin level and then minus your ascites albumin level from it if you get more than 11, um it's likely transitive. So due to um portal hypertension that could be due to liver cirrhosis, it could be due to heart failure and then um ascites that's exudative. So a serum albumin ascites gradient of less than 11 could be due to nephrotic syndrome or it could be due to malignancy. So it generally presents with abdominal distension and in some patients, it's really obvious like they look like they're pregnant. Um It'll be dull on percussion, you'll have a positive fluid thrill and a positive shifting dullness for your investigations. Um You may want to do an ABDO ultrasound scan. Um but your definitive investigation is gonna be an acidic tap, abdo ultrasound scans are helpful because you can see is the liver cirrhotic. And then in practice, you can ask the ultrasonographer just in the request like to mark the area where there's the most ascites. So you know where to go for your ascitic tap. Um Next slide, please. So for your ascitic tap interpretation, as we said before, um your serum albumin albumin ascites gradient um will tell you whether it's trans or sedative as well as your LDH. So if it's less than 225, it's likely transudative. If it's more than 225, it's likely sedative. That's because LDH can be a marker of like inflammation in the body. So more inflammation, more likely it is to actually be ed and if you've got a high protein, so more than 4 g per deciliter, that indicates that there's some level of infection there. So whether that's SBP, whether that's TB and you also want to have a look at your white cells. So if it's less than 250 there's no active infection. If it's more than 250 that's abnormal indicates that there is an infection if there's a neutrophil predominance, um it's likely SBP and if it's lymphocyte predominant, it's likely TB. So looking at that patient LDH was less than 225, serum albumin ascites gradient would have been more than 11 protein, was less than four white cells were less than 250. So all of that indicates that it's a transit of ascites without an infection. So for management, you don't want to get daily weights on the patient to see, are they, are they actually offloading this fluid? Um Again, you want to do a fluid balance chart. Ideally, patient would be in a negative fluid balance and you want to sodium restrict the patient. Spironolactone is your first line diuretic for ascites. And if you're finding they're not actually losing weight, you can add in furosemide. If the patient has spontaneous bacterial peritonitis, you wanna give IV cefotaxime and the criteria for giving patients oral Cipro for prophylaxis is if they've got cirrhosis and if the protein levels are less than 15 on the acidic tap. And then, as I said before, you would only do a large volume paracentesis if there's tense ascites, which is something you'd find on examination and then just to go over decompensated liver disease. So this can present with a number of different um conditions. So it could be jaundice and you typically see a mix of conjugated and unconjugated bilirubin. And you'd also see um a hepatic picture of um cholestasis. So your AST and your A LT and your transaminases will be raised more than any ra in ap. So, decompensated liver disease can present with ascites or SBP, you can also get patients presenting with hepatic encephalopathy. So, confusion and to manage this, you want to make sure that patients are on lactulose, that's first line. And if that isn't helping to resolve their hepatic encephalopathy, you'd want to give rifAXIMin as well. And these will help to kind of limit the amount of ammonia that's in the body, which is thought to be the cause of their encephalopathy. Um and if patients are encephalopathic, they can often have asterixis. So kind of that flapping tremor patients can also present with renal impairment. They may have hepato renal syndrome, they may have gi bleeding from varices and they may also become septic. So, question six, just give you another minute for that. Ok. And just before we go on to question six, just for when you're actually on the ward, if you think a patient has decompensated liver cirrhosis, um you can find the basil bundle online if you just google it. And that's a really helpful tool just to kind of walk you through looking for different signs and how to manage them. But on to question six. So you've got a 37 year old man who presents to A&E with a two day history of persistent right, upper quadrant pain and nausea. He has previously experienced similar pains, but this is resolved spontaneously on examination. His temperature is 38 degrees. His pulse is 90 BPM and he's got a positive Murphy sign which investigation is first line for this patient. So the correct answer is C which is an ABDO ultrasound scan and the patient is presenting with signs of acute cholecystitis. Um, and an abdo ultrasound is the most sensitive for actually having a look at the biliary tree. Um, seeing whether you've got like an inflamed thick called gallbladder and seeing if there are any stones, either in the gallbladder itself or in the common bile duct. So for right upper quadrant pain, um, it's helpful to just kind of think of how like gallstones, acute cholecystitis and extending cholangitis can be differentiated. So, gallstones will present with right upper quadrant pain. Um that typically resolves spontaneously. Acute cholecystitis is the same right upper quadrant pain. But patients often have fevers and then ascending cholangitis has fever, right upper quadrant pain and jaundice and that's Charcot's triad. So, an ABDO ultrasound scan is gonna be your first line investigation if you're not 100% sure, uh whether this or you think there may be other abdominal pathologies, you may want to do act Abdel vs just to help rule that out. And if you see gallstones on the ABDO ultrasound scan and the patient's got cholecystitis or cholangitis. You may want to do an M RCP as this is more sensitive for having a look at the biliary tree in order to manage gallstones. Um It's typically an outpatient elective laparoscopic cholecystectomy. Acute cholecystitis is managed with IV antibiotics and you would ideally get the patient a lap Coly within one week of presentation. And then for ascending cholangitis, you'd want to give IV antibiotics again and a lap call, but not necessarily within a week. You'd want to make sure the patient's not septic first. Ok. Question seven. OK. Question seven. So a 40 year old man presents to his GP with recurrent episodes of heartburn and epigastric pain after eating. He is systemically. Well, he's not on any prescription or over the counter medications at present. So, what's the most appropriate management plan? Um, for this man, the presentation is indicative of some sort of peptic ulcer and a really common cause of peptic ulcers is H pylori. So you'd want to do a urea breath test to actually confirm whether or not the patient does have an H pylori infection. Um, you don't want to just give empirical treatment, it's better to actually know, um, and actually do the diagnostic test. So that's why questions c no answer. C sorry. Um, is the right answer. I don't think we're at the point of referring for an OGD just yet. We've not actually done any sort of trial of medical management. And the patient doesn't necessarily need lifestyle counseling at this point in time for his presentation of peptic ulcer disease. If a patient was presenting with, you know, and they've been taking multiple courses of nsaids, you may want to counsel them on the fact that these are gi irritants, but this patient isn't actually on any medications at present. So for peptic ulcers, you can separate your causes into A B and C. So A could be alcohol. It could be an autoimmune condition that's causing that peptic ulcers. And it could be b which is a bacterial infection which is h pylori. It could be c just chemicals or medications. So, common, um, medication causes of ulcers are nsaids, bisphosphonates and steroids. Patients typically present with epigastric pain if it's caused or triggered by eating, it indicates that it's a gastric ulcer. Whereas if it's relieved by eating, um it's much more likely to be a duodenal ulcer. So for your investigations, you want to do, you can do a urea breath test for H pylori, you can do a stool antigen test for H pylori. Um And if you've already tried the patient on um PPIs and H two antagonists, you may want to refer for an O GD or you may want to refer for an O GD outright if the patient's got any sort of red flag symptoms. So, if they lost weight recently, um you know, anything else that could indicate, um could indicate this patient has a more sinister underlying condition. So, for your management, if your H pylori tests are positive, you want to give um two antibiotics and A PPI. So typically this is amoxicillin, Clarithromycin, and omeprazole. But if the patient's panallergic, you can give metroNIDAZOLE, Clarithromycin and omeprazole. Um But some sort of ppi and two antibiotics if the patient doesn't have a positive H pylori test, um PPI S would be first line So omeprazole, lansoprazole, anything like that, apologies. Sorry, we've got the wrong slide there. Uh Bear with me. Sorry, I just accident got an answer there. Sorry about that. I'm sure a few of you already saw that answer, but let's go on to question eight. So I'll set the timer for this as well. So you all have a minute. Ok? So hopefully you should all be familiar with this presentation by now. Um So we'll quickly go through it. So a 17 year old female, so already you're thinking someone a bit younger presents in the emergency department with periumbilical pain. So, buzzword there. So pain around the umbilical region, the pain is sharp in nature, exacerbated by coughing and came on gradually over the past 12 hours. So relatively acute uh onset on examination, she's unable to stand on one leg comfortably and experiences pain on hip extension. So we'll discuss what sign that is shortly. Um There's no redo tenderness or guarding pregnancy test is negative and temperature is 37.7. So they have a mild fever and they're not pregnant. So we're not thinking it's a gynecological cause blood to reveal leukocytosis. That's predominantly neutrophils, which investigation is most sensitive in making a diagnosis. So the answer here was ct abdomen, er abdomen and pelvis. Er So from the presentation, er we're thinking that it's possible appendicitis. So thinking about the age of the patient. So usually if a young patient comes into the surgical, er, clerking unit or EC, er, surgical er, emergency care unit and they're a bit younger. The first thing you think is appendicitis. Um, and so they have the pain around the umbilical region. It doesn't have the classic, um, radiation to the right iliac fossa because in younger patients it's not always the case. Um, so they might just be behaving slightly abnormally or just have this umbilical pain or it's just too acute in an onset for it, for it to have radiated by this point. Um And with an appendicitis classically in the past, you can, people would suggest doing an ultrasound abdomen, er which you still see uh nowadays as well, but it's just not as sensitive. So if you're very suspicious clinically and it doesn't appear on the ultrasound, you then do act abdomen anyway. So often people just kind of skip that step and do act abdomen. So from an exam standpoint, uh it would be the right answer as well. So we'll quickly do another question uh similar in nature to this. So everyone takes around a minute for this as well. Ok. So hopefully that's been enough time. So the answer here is Robson's sign. Um So Robson's sign is when you palpate in the left iliac fossa, it elicits pain in the right iliac fosaa for the patient. Very simply, I'll just remember that as if you remember the letter R thinking about the right side. So if you've had that on the left, you get pain on the right. So R and Rob saying for that, er mcburney's point we'll discuss, but it's more so the landmark, er, or the anatomical location of the appendix. Um So a is when, if you extend er, the thigh um in the left lateral position, then it can cause right idiot fossa pain. Um And then you have your ultra sign, so you flex at the hip, 90 degrees flex at the knee, 90 degrees. And then if you internally internally rotate the knee, then that also uh causes some pain for the patient as well. So very quickly we'll whizz through this. So, appendicitis, inflammation of the appendix etiology wise, just remember the phrase boot rock um or if you want to be more medical folate. Um And so there's some sort of obstruction into the stump of the appendix, er which is then causing it to become inflamed. Um It a surgical emergency, anyone between the age of 10 to twenties start thinking about that as something you want to rule out cos it is an emergency case. Um in terms of the symptoms, abdominal pain, classically, you have periumbilical radiating to the right iliac fossa. Patients are often quite nauseous and might have vomited, they often have a low grade fever as well. So you can see that from a stem of the question there as well. Um So that's the highlighted parts that are relevant in terms of the signs, we've already discussed them the top three, if they're a bit more peritonitic. Um, so there, there's a risk that it may have perforated as well. So in that case, if you do, er, rebound tenderness, um, they're really guarding, they're really quite tender and you're thinking there might also be a possible perforation, which is definitely an emergency more so an emergency. Um, and mcburney's sign, we, we touched on earlier, so it's the anomal location. So remember it's a third of the distance from the aces to the umbilicus. Um, so remember that as well from an exams standpoint, you, you don't ever really mention that phrase clinically though just for your exams, um, managing patients, er, because it's an emergency likelihood is they will need to go to the theater, er, for an emergency appendectomy. Um, so try to keep them nil by mouth. If it's the next day, they're nil by mouth in the evening or early morning at around 2 a.m. fluids, if they're impossible shock, uh, patients are often started on antibiotics and especially if you know, surgery is going to be delayed by a day, for example. Um, and then a laparoscopic appendectomy is the procedure that you would do. Um, some patients, it might not be appropriate to do surgery there there. And then, so you can treat them with antibiotics and they can have an appendectomy a bit further down the line. But it really depends on how the patient is clinically er complications. As I mentioned, it can rupture or perforate and that can cause peritonitis and therefore the signs of peritonism, which we touched on like the regarding rebound tenderness um and it can cause a possible local collection as well. Um So in that situation, you would have to contact interventional radiology. Um they would do some sort of ultrasound guidance to think about draining the abscess questions. Um So again, one minute on the board. Ok. So answer here is diverticulosis. So we'll quickly read through the stent together. So it's a 65 year old gentleman slight on the older side, we wouldn't say they're necessarily geriatric or anything but anyone in that sort of age range, it's, and they have rectal bleeding or pr bleed, then it's cancer until proven otherwise. Um, but you can kind of elicit that from the history. So I'll have a look at what er, the stem says. So there's blood in the stool for the past few days. Um So it's more of an acute bleed. But yeah, uh he denies any fever, chills, nausea or vomiting says that the bleeding is painless. So that's important. So as the pain is bleed, um and there's not really any other uh remarkable symptoms. Last colonoscopy was five years ago but only showed some diverticula, er, but no polyps or cancer. Um, temperature is 37. So they're afebrile, er, they're not tachycardic respiratory rate is normal, so less than 20 BP is also very normal. Uh rectal examination does not report any abnormality. What is the diagnosis? Um, so there isn't anything for cancer in the stent, but if they just have a pen bleed and, you know, they have a history of uh diverticula, then like most likely diagnosis is diverticulosis. Uh, there wasn't anything in the stem, er, regarding, you know, floor symptoms like weight loss, et cetera for cancer. But fortunately, there wasn't anything in the answers for that, that would be cancer. So that would have been quite mean if there was um let's quickly have a look at diverticular disease. The reason I put that question in is the definition is crucial from an examination standpoint just in general when you're on the wards in general surgery as well, it will be very helpful. Um Cos they're always using the different buzzwords, er, thinking about etiology. Er, so again, er, quite important to know uh for, for your exams. So remember in the large b, you have your tinea coli. Um so these run longitudinally along the colon. Um so they, they present with these sorts of bands and in between them, you have the mucosa. Um And so it's in between the tin tinea coli, you have the herniation, sorry, not the herniation, the, er, the outpouchings developing. Um Just remember if someone presents with left sided abdominal pain and apr bleed, then you're definitely thinking uh more So, er, diverticulitis, sorry, or diverticular disease. And if there is pain and it's symptomatic, then you're thinking, er, diverticular disease, um, as opposed to diverticulosis, which is just the presence, presence of the diverticula. Um, because in the western world it's more so left sided. So the descending codon, the sigmoid, remember, you don't find diverticula in the rectum interestingly, you can find it in a small bowel as well for some patients. Uh, But that's another thing. Uh in terms of the risk factors, it's always good to ask the patients, you know, have you had chronic constipation in the past? Uh They often describe some sort of history of that but it is often just age related. The older you are, the more likely you are to have diverticular disease, diverticulosis patients are asymptomatic, they might just have blood in the stool. So, pr bleeder. So in that case, the top two differentials are just gonna be colorectal cancer or diverticulosis or presence of diverticula diverticulitis is when you have more, when you're more symptomatic for it. So, um you have uh abdominal pain, like I said in the western world, it's more likely to be left iliac fossa if it's right. Iliac fossa, don't rule out diverticular disease because it might just be an abnormal presentation for the western world or people from other parts of the world. Um They often have a fever cos there's some sort of infection, inflammation. They're often tachycardic and they might be distended. Abdominal, the abdomen might be distended but not always the case. So in the stem, we basically rule out any features suggestive of diverticulitis. So it's more likely to be diverticulosis er, in terms of the investigation and do your bloods. The main thing you're looking at for inflammatory infection markers if they're raising this small. So diverticulitis and the management is very different for that. Um I've written very EMA but it's not necessarily seen as much as with anything in gen search any issues, any sort of possible changes, patient might deteriorating ct abdomen uh from an exam standpoint, they, they'd often be happy with that. It's it's the imaging of choice for most things. Now, abdomen related um and a colonoscopy a bit further down the line. So it's just important to note if there is an acute inflammation or infection, you would not do a colonoscopy acutely because if you put a camera up whilst there is active inflammation, there's a great risk of perforation. So often what you see is if it is diverticulitis. So inflammation or infection er of the diverticula, then you, you manage that acutely, you might then send the patients home on a bit, uh a shorter course of antibiotics to finish their course. And then you book in a colonoscopy a few weeks down the line just to make sure that inflammation is settled. So you want to do that acutely, but it's definitely worth doing especially if it's new disease and also to rule out a possible cancer, especially CT might, if, when there's active inflammation, the CT might say something along the lines of fat stranding something like that and it might show a possible mass, but you can confuse that for inflammation. Um So colonoscopy will kind of help because it checks for a mass. And also just to confirm the outpouching or the diverticular presence in terms of managing it. Uh Just remember you can't reverse the growth but you just prevent progression. So you prevent worsening of things. Er, so it's largely er er lifestyle management. So there's a lot of advice you give patients leaflets. So that includes fiber advice, et cetera, make sure that they're well hydrated. So you're just trying to reduce the risk of constipation. Regarding the f the diet, you also often advise patients to have less seeds, those sorts of things, things that won't be digested, but they can get lodged in the diverticula and they can cause blockage obstruction and then uh inflammation or infection thereafter. Um And yeah, weight reduction, all of these things reduce uh intraabdominal pressure which reduce the risk of further outpa developing if it's uncomplicated diverticulitis. So there's definitely an infection because you have raise inflammatory markers and whatnot, but the patient is otherwise clinically stable. It's often just a case of giving them some oral antibiotics and you can even discharge them on that. If it's more complicated, they definitely a bit more symptomatic, very tender and whatnot. Then yeah, you, you do the other conservative management like giving them fluids analgesia just depending on what clinical presentation is in front of you. Um If there is a collection, often, sometimes you see like a little perforation and after a perforation, you can get like a little collection form around it. In that case, you might then refer to interventional radiology and they can consider draining the abscess as well. Again, guiding via ultrasound. Um Remember with analgesia, so this is really important, don't try to avoid anything that's stimulant. So things like your movicol um So try to give things more like laxido um which isn't gonna stimulate your bowel rather, it just going to absorb water into the stool to soften it and then um avoid opioids. Ideally cos that can make people more constipated. So m really try your best to work up the who ladder for pain. So start with paracetamol. Then you can go to codeine dihydrocodeine and then go to slightly stronger opioids like er oral morphine, IV morphine complications wise. Yeah, you can get an abscess there, perforation. If it perforates and some of the content goes into the abdomen, then you can get peritonitis. Er So that's important. All right. Moving on to the next question. So again, one minute on the board. All right. So that's the minute up. So the answer here is acute pancreatitis. So let's quickly er discuss this one. So it's a 53 year old gentleman, er, presenting to the ed, er, so they have severe mid epigastric abdominal pain that radiates through to the back. The pain improves when the patient leans forward, er, and assumes the fetal position, er, or assumes the fetal position. Sorry. But it worsens when, er, they inspire deeply. Er, he also complains of nausea, vomiting and anorexia gives a history of heavy alcohol intake. So the answer here was acute pancreatitis. So let me just quickly discuss that any time anyone has epigastric. So upper abdominal pain don't rule out the thorax. So think about the thoracic differential. So your heart attacks, uh there could be a pulmonary embolism, er, because it could just be on the border or a slightly abnormal presentation. Um and then think about the abdominal stuff as well. So that can be your acute pancreatitis around there. It could be the biliary tree um as we discussed earlier. Um but there's other things that are more pathognomic for acute pancreatitis here. So, er, pain improving when they lean forward is you do see that, that sign clinically, it's worse on deep inspiration. So don't, so when patients have that you might be thinking pleuritic chest pain like pulmonary embolism, which is completely valid to think. But just remember when you breathe deeply, it's basically compressing on this inflamed pancreas, which is also why you get that sort of um, er, pain that resembles pleuritic chest pain. Um they complain of nausea and vomiting very, very common and often patients vomit a lot with this. Um and they have a heavy alcoholic intake. So you're thinking risk factors already for acute pancreatitis here. Um and a possible underlying cause tachycardic, tachypnea, febrile, er, with hypertension. So this patient is it possibly quite unstable, they're agitated and confused. Uh they, they have a temperature as well. Um they're tachycardic and they appear quite pale, extremely tender. So often they are very tender when you palpate them. And here's another thing that's quite pathognomic for acute pancreatitis. So, the amylase and lipase are raised. So from your standpoint, even mine, er at f one level, there's not many other things you consider when amylase and lipase are raised. Uh So as soon as you see that in a stem, just automatically think acute pancreatitis. Um so very quickly. So inflammation of the pancreas. But remember this, if it's acute because you can have chronic pancreatitis. But if it's acute and you resolve it well, er then it can kind of settle and the damage can be reversed if it's not resolved. Well, then it can become more chronic once there's permanent damage etiology. Um So you have the inflammation in the pancreas, it releases various minerals. The main one that's calcium, it calcifies the pancreas. You get the breakdown of cells and then you basically get this autodigestion. So the cells break down, they release all the enzymes that the er pancreas produces and those enzymes then go on to digest the pancreas itself. And yeah, and that obviously damages local structures and whatnot and that's what causes the inflammation and the pain causes. I get smashed. Um, so you'll use this in exams and you'll use this on the wards as well. So when you clerk someone, you're thinking has acute pancreatitis, you're literally going through this point by point just to think of the underlying course, cos with quite a few of these things as we go on to the management, you'll see that you have to find treat the pancreatitis, which is often just more like symptomatic management, like fluid management, but then actually get into the underlying course. So this doesn't happen again. Um Key ones we need to think about, it can just happen. So it can be idiopathic idiopathic. But that's obviously, once you've ruled out all the other things, there's a diag, there's a diagnosis of exclusion that uh so check gallstones. That's the big one. Alcohol use is the big one. Trauma. That's the big one. So it's quite nice that those are actually separated in terms of the pneumonic, er, because those are the three, you're, you're thinking about, think about their medication. So it could be steroids, the possible infection, it can be autoimmune. So you can do a pancreatitis screen which what I won't go into, er, with much depth, but you can send off a screen on that front. Um and Scorpion venom just don't even say that on the wards. Like, yeah, your consultant will think you're an idiot hypercalcemia hyperlipidemia. But sorry, from an exam standpoint, it's still worth knowing cos they might say, oh, they went to Amazon Rain Forest or something, hypercalcemia, hyper lipidemia. That's really good. So on the blood test check the calcium, check their lipid levels. E RCP. So that's actually an intervention. So, therapeutic intervention, but the possible complication is that it can damage the pancreas as well. So, I've seen this a couple of times where the patients come in a couple of weeks ago for E RCP and then they start developing this epigastric pain. And so they've developed acute pancreatitis secondary to E RCP. Um, and then certain drugs as well. So you check their medications. Um So the big ones you need to think about. So you evaporate steroids, which you've already mentioned, er, et cetera pain, severe epigastric pain, it can radiate through to the back when you think when it radiates through to the back. You're also thinking it could be a uh abdominal aneurysm. So think about that as well. Er, pain improves when they're sitting forward, er, nausea, vomiting, fever, possibly. Um, they'll describe some history of the co so if it's gallstones, they might describe a biliary colic picture. So they have pain that comes and goes in the right upper quadrant region. Alcohol, obviously, they'll tell you, they drink, they drink lots of alcohol. Well, in a lot of cases they don't tell you that. But, er, you can refer to like, substance misuse and they're, they're often often a bit better at really getting to the bottom of that alcohol history and they might be hypovolemic if they're more unstable. So, two signs from an exam standpoint, you don't really see this clinically, but just remember gray turn signs. So I remember turn like turning around the side. So it was, that's the bruising on the flank of the sides and then colon sign just, yeah, that's a periumbilical bruising investigations wise. Amylase lipase are very specific. Lipase is more specific than amylase. Er So if you have a choice of sending bloods off ideally do the lipase but do both. Um ultrasound, not as sensitive. So, ct abdomen, like I said, abdominal stuff just think that and that's quite good at showing the, the pancreas just so you're aware I won't go into it in much depth. But the pancreas, if you look at it on a normal CT is just quite fluffy, re nicely rounded off somewhat. But uh when you have acute pancreatitis and you have the inflammation that fluffiness it, it all just kind of becomes like one color. Um So yeah, so you can look into CT scans yourself and then you're thinking about the causes as well. So if you're thinking it could be your gallstones, you can do ultrasound to check for the gallstones. Um, if that doesn't show you can then do an M RCP that also is, is more sensitive for gallstones. But like I said, calcium levels, uh, lipid levels as well check that if you're trying to find the underlying cause, um, from an exam standpoint, it's a really good the modified Glasgow score. Um, and based on this, you can determine like the severity of the pancreatitis. Um, but ultimately, the management is very similar depending ov ir irrespective of the severity. Er the only thing you need to think about if it is very severe. So the patients really unstable, then you're thinking they could go to HD U for the for closer like fluid management and whatnot that in terms of the management. So from an exam standpoint, just remember you'll get so manage the patient and what symptoms they've come in with. So they're gonna be in a lot of pain. Give them the analgesia with pancreatitis. You have quite a lot of inflammation going on in the body. Um with that, you can get a lot of th third splicing of the fluid. So they go into the extra vascular compartments. Um And because of that, you're going to be intravascularly deplete. So the the blood uh in your vessels. Yeah, that's why they're more likely to become hypovolemic. So basically when a patient comes in, you start pumping them with fluids. So give them some stat fluids, give them over an hour, then over two hours again, it really depends on the patient, but from, from, from your standpoint, uh, just pump them with loads of fluids. That's basically gonna be the mainstay of your treatment, trying to treat them conservatively and dealing with their symptoms and then dealing with a cause after that. So if you know that they have gallstones, so if you've suspected it and then you do an ultrasound and if that doesn't show it, you do an M RCP. So an MRI, which looks more closely at the bilary tree. If that has shown gallstones, then you would do an E RCP down the line which er, can, er, resolve that. Um, if so, one of the complications is that you can develop pancreatic necrosis. So if the patient's inflammatory markers really go up, they're really, really unwell. Um And you do another CT scan, the CT scan should, can show necrosis as well. Er, so that's one thing to think about and one and one solution to that might be necrosectomy. So they literally the bride and get rid of all the necrosis. Er, and in those patients, you often give antibiotics. So remember, although it is inflammation of the pancreas, it's not an infection. So with patients, you do not typically start them on antibiotics, you only start them on antibiotics if it's necrotic and if you're s and necrosis doesn't necessarily always mean infection either. But if it's necrotic and you think that there's an infection that then you start this patients antibiotics. So acute hepatitis don't automatically think antibiotics is more so as pain fluids and then dealing with the underlying cause. And so that also includes substance misuse. So if, if you think it's because of an alcohol history involve the substance misuse team and then try and wean them off alcohol, all of that stuff. Um, for your exams, complications wise, there's a few, you need to know just some buzzwords, but I won't go into much depth like pseudocysts. So you can develop cysts after the uh after pancreatitis, if not managed correctly or in some cases, it is still managed, but you can still develop chronic pancreatitis. You're at more risk if you've experienced acute pancreatitis. Another one that's really important to know, er, which I've seen on the clinic. A coup er, on the wards a couple of times is they can develop er, acute respiratory distress syndrome. So if a patient has acute pancreatitis, they will already kind of er, describe this pain where their breathing is limited cos when they breathe too deeply, the lungs compress onto the pancreas. But sometimes patients, they might actually start like desaturating re become really tachypneic. So don't just think, oh, it's because the pancreas or the lung function is limited because of the inflammation. It could be that they're actually developing a respiratory distress syndrome, er, which is obviously more severe and then HD U usually get involved there. So remember there's most patients or a lot of the patients, their breathing will be limited somewhat. That doesn't necessarily mean they actually have lung injury, but that can develop if the pancreatitis is more severe. And yeah, and because they become intravascularly deplete, you get all the third spacing of the fluid, obviously less fluids in the, in the blood or the vessels. And so you can get AK I usually because of hypervolemia. Um, so you again, that's why fluids are so important. Ok. So this is a bit of, this is more of a double question. Uh, but it's related to the same stent. But so I'll give you a little bit longer for this one if you all have a read through. All right. So that's been around a minute. Ok. So we've gotta go through the answers. Um, so answer here is an inguinal hernia and then referring them routinely for surgical repair. So let's quickly look at the stent 50 or eight year old patient. So again, with a hernia, they're usually a bit older, but it's very unlikely for someone younger unless there's some er, serious pathology uh for them to develop a hernia. So they have no other past medical history, they have a right sided lump in the groin. So immediately you think hernia when you see that been present for around a couple of weeks, but it disappears when he lies down. So it's reducible clearly, and the swelling is reducible and not causing any pain. And they're not really symptomatic from it. It's just there and present. So 2 to 3 centimeter lump in the right groin, superior, superior medial to the pubic tubercle. So that's really important for the location. Um So that's basically what gives you the answer of inguinal hernia. So if it's superior medial, so a bit higher, bit closer to the middle, then the pubic tubercle then immediately think inguinal hernia and then we'll look at femoral hernia shortly. In terms of the appropriate management here, you can just refer them routinely because it's reducible, it's not causing any pain. So there's, it's very unlikely for something more complicated to have happened here. Um So, but you do want to repair it a bit further down the line, especially if this patient is otherwise. Well, they're not, they, they are suitable for surgery. So they haven't got like loads of comorbidities. Um So you want to repair it down the line with a mesh repair. So you put a mesh there, it reduces or prevents it from reoccurring and that way that prevents more serious complications that can develop from a hernia, which we'll touch on shortly, very quickly the definition. So you have protrusion of abdominal compe content er through the abdominal wall, uh through an area of weakness. The two main ones you need to know about inguinal, which is way more common than femoral. Um So, and if you forget, it's just more likely to be an inguinal hernia. So you can always kind of assume that causes it due to increase in intraabdominal pressure. So people who've done like boxing or weightlifting in their past, they, they're more likely to develop it. Um, yeah, chronic coughers, anything that causes you to like, tense your abdomen. Er, it is more likely to cause a hernia if you have a look there, the main thing you need to think about that is a serious complication is an obstruction because of A B, if the bowel content also goes through into the hernial sac, then it doesn't always happen. If there is bowel continent, it doesn't always cause an obstruction, but it can. Um And so if the patient isn't able to pass any farting, any poo, they really distended stomach and they have this hernia which is causing them a lot of pain, then alarm bells should be ringing or else they've got obstruction and possibly incarcerated hernia. So if, yeah, the blood supply is cut off as strangulated and that can cause incarceration. Um All right. So as I said, inguinal is superomedial. So a bit higher closer to the middle is inguinal hernia and it's above the pubic tubercle. So you should be able to palpate that on your cells and on patients. Um if it's below that line, a bit more lateral, then think femoral hernia. But remember it could also be something like a hydrocele, which I won't go into now, but look into differentiating hydroceles with like femoral inguinal hernias. I think it's really important. Uh But I won't go into that now. It's about trying to get above and beyond um, the protrusion. All right. So the inguinal hernia, for the sake of time, I won't go into much depth, but we're going to upload our slides onto metal. So you can have a look at that then. Um, and it's to do with the canals from an exam standpoint, I would learn this, uh, clinical standpoint. You don't really need to know this too much. Uh, other than if you actually go into the theater to do it. Um, remember inguinal hernias, a buzzword, Hesselbach triangle, you often find it in, in between these anatomical landmarks. So it's the lateral border of the rectus abdominis. Um, it's just below the epigastric vessels, um, and above the inguinal ligaments are in that sort of triangle. Um, all right. For more hernias. Yeah, through the femoral canal. I'll leave that, er, for now. Symptoms. Yeah. Patient of often asymptomatic. They might, they'll have a hernia, they'll go to their G PGP will say, look, you're fine, you can just kind of tolerate this and we'll then refer you to the general surgery team. They can put you on for the elective list for a mesh repair if you'd like. Uh, so often patients might be waiting for that and then some complication happens if they then need an emergency surgery, like incarceration or bowel obstruction. So they might have the hernia for some time. Um, some might not even notice it. Er, it's more prominent when patients cough. So if there's a query, hernia, I ask the patient to stand. I go, I do my examination straight away by them standing up because it's just easier for you to see and whilst they're standing as well, get them to cough. Um, and the other thing you always wanna do, can you reduce it? So, check if it's a hernia, er, get them to cough, can you reduce it as soon as you can't reduce it? Then already alarm bells are going, then you want to involve your seniors. Um. All right. And that it won't cause pain unless it's a bit more serious, like incarcerated or strangulated. So, as soon as there's pain with it, then again, I think that's probably more serious managing it. So, trying to prevent them doing things that aren't strenuous that would increase the intraabdominal pressure. Er, so that includes like losing weight, trying to limit how much, er, lifting they do some complicated. You do an elective mesh repair. So a bit further down the line and it's often done laparoscopically if it's a bit more serious, like you have an obstruction or there's a such strangulation, you often do, er, a laparotomy for that. Er, cos it's not just resolving the issue, you need to kind of, yeah. Er, you need to look at things a bit more, er, closely and we've discussed the complications already. All right. So, question 13 again, a two part question. So I'll give you a bit of time to really go over this. All right. So that's been a minute. So the answer here is an anal fissure, management wise. We'll discuss that shortly. But that's the answer. Topical GTN cream and then advising management, er, lifestyle, er, approaches to the management. Er, so the patient comes in, they ha they have quite a severe pain in the anal region. Um, they have fresh red blood on the stool. So as soon as it's fresh red blood, you're thinking anatomy is slightly closer to the anus. So that's like the descending colon, er, rectum or the anus, er, if it's a bit darker and b blood, it's a bit further. Uh, it's a bit more proximal than that and often, er, upper gi in nature. So, yeah, if it's really painful, fresh red blood just immediately think, er, anal fissure and the other key thing. Sorry. No, it's not written here. Um, he only opens his bowels once a week since he was, since he was young. So it implies chronic constipation so often when patients are quite constipated as you're like really straining, it increases the risk of a tear happening. Um, and therefore anal f in official, you have some sort of split in the mucosal lining. Um, and you get pain on defecation. So there's a very close association between trying to postal and then there's pain uh, being exacerbated. Um, remember chronic is a, if it's more than six weeks, um, risk factors for constipation having hard stools, pregnancy is a big one as well. Cos you have a lot of BP, um, anything related to constipation. So opius as well, uh cause you to be constipated, you get this pressure of blood pa patients often describe it as like passing glass. Er, because if you think about it every time you strain, you pass all it, it causes um contraction and therefore it literally spreads that anal fissure every time. So it just literally it tears and tears. Hence why conservative management like softening their stools, all of that is really important. Um, so that they don't have to strain as much and that prevents it worsening and also helps er, er healing of the fissure. And you get this fresh red blood on the toilet paper. If you see fresh red blood, you're also thinking hemorrhoids, which we'll touch on shortly. It's a clinical diagnosis. So you're not gonna do any sort of crazy investigations. So remember, don't even ask the patient to do apr exam. Don't write that down as one of the answers to the exam and never ever do that on the ward just to save you time. Cos even if you suggest that the patient will tell you to go away cos they won't be able to tolerate that at all. Er, management wise, a conservative. So, just think constipation is what's gonna make things more difficult. So, manage that. Give again, give, um, Laxido. So, um, that's, that will soften the stools by absorbing water into the stools. Not anything that's stimulant, cos that again, that's just gonna cause you to push hard stool through the fissure, er, which worsens things, the diet, having more fiber, having more water in your diet. That also helps soften your stools from a medical standpoint. You can give topical GTN. So it's a cream GTN. Really good analgesia, topical dilTIAZem as well. And that's been known to help. Um, most patients will heal in around 21 to 2 months. If not, then you can think about other things as well. So like botulin toxin, er, that literally like relaxes the muscles. Um, so, er, and yeah, so obviously you can imagine that prevents it worsening and it improves it and then you can do a sphincterectomy as well. So you literally do a cut into the sphincter and that again opens things up. So there's less strain when you're pushing through, which helps with healing. Uh, question 14. So again, a minute report of this. Um, sorry, everyone, it's gone a little bit over. I appreciate you might all have to go away if you do choose to go away and you quickly leave. I really, really appreciate if you could do the feedback form, um which I'm not sure is on here, but uh we'll send that out to you after the session as well. All right. So the answer here is grade two hemorrhoids. So part e um So yeah, again, you have fresh red blood as soon as you start suspecting like there's a mass coming out um of the anus, then you're thinking more so hemorrhoids um or it can obviously be a, an anal cancer as well. Uh But in this case, it's what it's, the mask comes out and it spontaneously resolves. So it's going out and then back in and that's what you need to know for the grading, whether it spontaneously reduces or that the patient needs to manually reduce, but we'll touch on that shortly. Um And again, yeah, so because there's fresh red blood on the paper. So again, always think hemorrhoids is an anal fissure and the key differentiation is pain because there's no pain. There is, there are, there is a type of hemorrhoid which can be painful as well, which we'll discuss now uh too. Um So buzzword is the pectinate line or the dentate line. So that's this line that separates the superior er portion of the anorectum and then the inferior portion um and the hemorrhoids er can develop above or below. So they can be internal hemorrhoids or external he hemorrhoids, depending on whether they're above or below that dentate line. That's more. So, academic and that they can definitely answer that in the exam grading is really important. There's no prolapse at all. Er, there's just these prominent vessels and only bleeding. So this, you do, you, you can only really say from, er, when you do an investigation, which we'll discuss grade two mass comes out. So the hemorrhoids come up, they spontaneously reduce if the patient has to physically m, or like, manually reduce it themselves. And that's grade three and grade four, they're just not able to reduce that at all, just loads of the content that's come out. Um And that's for internal hemorrhoids just to be aware. Um So yeah, you get, we've already discussed the p presentation. So continue in terms of the investigation, you do an endoscopic examination, you put a scope up and that allows you to visualize things more closely. Um And that confirms the diagnosis, but often you can just say it's hemorrhoids from the clinical examination, but you always do this just to kind of see the staging as well. Um manage them conservatively often. Um So again, constipation advise discourage straining cos that can worsen the hemorrhoids. Er but often based on the severity, there are different approaches as well. You can use steroids. So steroids can kind of shrink the hemorrhoids but it's not er completely curative. The the thing that is very curative is a rubber band ligation. So they literally put this rubber band band around the hemorrhoid and then over several days to weeks um that cuts off the blood supply to the hemorrhoid and it kind of just necroses falls off and then you excrete it. Um And that's the hemorrhoid dealt with and it can reoccur but with a lot of patients that just deals with things and you can also do a surgical hemorrhoidectomy if it's completely nonreducible. Um And yeah, so that's more of a theater or surgical approach. Uh So yeah, rubber band ligation you can do in as an outpatient. Uh whereas the other one is in uh in the, all right. So the hemorrhoids can become thrombo. So if there's reduced blood supply going through, they've come thrombo, they become really painful and they do become very purplish. Uh So you can often see that from a clinical standpoint. Um And this is a bit more, this is more of an emergency. You kind of want to bring patients in. You might have to think about uh a surgical approach for this question. 15. So again, minute on the board for this. All right. So that's been a around a minute. Er So the I answer here is IBS. So it's a young lady. So if they're young and they're female already start thinking about IBS once they have tummy pain, um it's mainly lower abdominal pain. It's a bit crampy, but it goes away after she opens her bowels, there's a bit of an association with passing stool. She says that she goes to loo, er, to pass stool, er, several, a number of times per day and it can be watery. So there's a bit of diarrhea, er, diet cos, there's a burgers, pizza and pasta. So relatively unhealthy. Um, everything else was normal. Examination, all the blood and whatnot. So, like the diagnosis, once everything else is really excluded, young female think IBS. Um, here it's not gonna be the other things. Gastroenteritis. You, you'd have those inflammatory markers. Um, yeah, you usually see C that you, you'd see some other stuff, but we'll differentiate with CDE. Now that's so whenever you see IBS, the thing to differentiate is, er, C DAC cos you have similar demographic. Um, but we'll discuss why this is also IBS. Um, yeah, it's not gonna be CDA because again, serology is all negative. So you would have sent off like a CDA screen hopefully. And that comes back negative. All right. Um, IBS versus celiac. So, very similar presenting complaints. They're bloated, they have, er, abnormal passing stools so it can be diarrhea. They have this tummy pain, er, just no IBS is a bit lower down in the abdominal region whereas celiac is general, but that's not 100% true. True for everyone. Er, IBS different foods can make it worse, but it's in celiacs are specifically things that have gluten in it. So you, for either patient, you ask them to keep a food diary. It's really important um so defecation can help with pain in IBS, but there's no correlation with celiacs cos you just always have that constant inflammation. Um, examination wise they're normal in IBS celiac. One thing you classically see is dermatitis if it's for, er, so there's sort of like a scaly rash which we'll look at, remember in IBS, you have to rule everything else out before you can say it's IBS. So you can't just sit up from a clinical standpoint. I think it's this. Um, and then see, actually do some blood tests, including IG att G and uh endoscopy can also show some results. IBS. Yeah, you get this recurrent abdominal pain pathophysiology isn't very well understood. Um It's some people su suspect it might just be er, er, possibly psychological um or it can just be idiopathic in people as well. Um, risk factors. Yeah. Anything that might have caused um psychological trauma in the past. Um, yeah, other abdominal conditions in their past medical history. But remember it's more common in females than it is in males. Um and it's usually younger patients. Um, defecation helps with pain often. Uh But again, not strictly true for everyone, but from an examination standpoint, that's something that they might throw in and the examination was normal and remember to exclude everything else is the things you're thinking, especially cos it's often a younger patient think about celiacs, think about IBD. So the test for that. Um And then it could possibly be a colorectal cancer. So you send off the screen for that as well. So that includes the fit test rather than the fog test, er, advise them lifestyle things. So there's things that they can do to reduce the risk of it happening. So avoiding certain there might be some sort of trigger. Uh hence why food diary is really important. So you can ask them to avoid those triggers. Fiber often helps trying to manage like the psychological side of things helps as well. So often when people are more stressed, they're more likely to get ibs symptoms. Like when people are advised. For examples, uh II had a few friends who just always develop IBS. Um Yeah, educating patients that's really important. Um medical standpoint. Yeah, there's a few things you can do, but it's not as commonly done. Er Celiac disease. This is an autoimmune condition and you basically get autoimmune response to when you eat um gluten and specifically a molecule called gliadin in the gluten. Um from a microscopic standpoint, you get this villous atrophy hypertrophy in the intestinal creps. Literally just memorize that cos you, you're gonna need to know that for celiac disease, they love asking questions on the pathophysiology for it. And those are the two lines. So there is actually a hypertrophy intestinal crypt which you remember it gliding is the specific molecule molecule and gluten. Um risk factors, family history of it is big if they're ig a deficient, er, that association with other autoimmune conditions including type one diabetes or thyroid thyroid conditions. And again, more common in females. Um, so, yeah, we've already discussed the presentation. The key one here that I wanted to highlight was dermatitis, herpetiformis. Er, so often you, you'll see that, er, on the elbows, there's like this scaly patch on the extensors. Um, you can also get it on the face, the neck, er, the scalp as well. Er, in terms of the investigations classic send off for IG att G. Uh, you can do Endomet Endomysial, Endomysial antibody as well. So, those are the two classic blood you send off and when you do an endoscopy, so they can have a closer look at the bowels. Um, this is where you see the atrophy and crypt hyperplasia and often they take a biopsy as well. Um, gluten free diet, nice and easy. That's how you would manage them. Uh, but you can also give vitamin mineral supplements as well. Um, and yeah, refer to a specialist cos there's really good specialist answers for that. Uh, question 16. So we're coming up to the last couple of questions. Uh, so not much longer left now. So, again, a minute on the board for this one. All right. So that's the minute done. Um, so the answer here is, uh, part D. All right. So we'll have a look at this one together. So 35 year old, uh, they're obese they're a female, so they have a history of gallstones. So, remember you're four f so female fat, 40 fertile. Um, so those are the risk factors for pe people having gallstones in the first place. In this case, we already know they have a known history of gallstones. They present to the ed, they have this right upper quadrant pain for around 16 hours. Er, sorry, everyone if you just bear with me, let me just quickly turn my lights on just to make sure you ignore. All right, um get back to it. So yeah, they have this right upper quadrant pain for the last 16 hours, er, vomiting, they're very nauseous. Er, they have a temperature of 39.8. So very febrile Murphy sinus positive. So we've already touched on this ninnis basically gone through. This are very, very quickly skimmed through just to add to it. But in this case, so this patient very tender, right upper quadrant. So you definitely want to have some sort of analgesia in there, which is why options D and E er, automatically the ones to go for. Um A has all paracetamol, but that's not really gonna get the job done for quite severe abdominal pain. So all just go straight to er D and E um patient can be put down on the hot cholecystectomy, this or to have the cholecystectomy within seven days. But the reason I haven't said option B is the best one because there's not, you're not thinking about the analgesia side of things there. Er, but that is definitely a valid option as well. And again, there's no antibiotics there. You do want to start these patients on antibiotics. Part C the E RCP, you do that if there's actual obstruction of one of the ducts, which there isn't necessarily a cholecystitis doesn't mean there's an obstruction of the duct that is acute cholangitis, cholecystitis is just inflammation of the gallbladder. Doesn't necessarily mean there's an obstruction of the duct. So you wouldn't need to do an E RCP here. You give them fluids. Ok. So they, they obviously have an infection. You want to give them fluids, they're nil by mouth. Sorry, they're vomiting, sore, going to be fluid depleted, give them fluids. So that's resolved that intramuscular diclofenac. So, um, an NSAID that's quite good at abdomin, uh, dealing with abdominal pain and again, because they can't swallow because, oh, sorry, they're vomiting. They might not be able to keep anything down. So it's good to think about IM or IV alternatives giving them er IV fluids and um, antibiotics. And the other thing you would then want to do is to think about doing a cholecystectomy within seven days. So, in a lot of centers you need to find out when the, the symptoms started. If you, if it is eventually confirmed to be cholecystitis from the scan, you need to find out when it is cos if it is within the seven day window, you can do a cholecystectomy there and then anything after seven days because of all the inflammation and infection that's been there, you can get this kind of fibrosis around the gallbladder. And that basically makes the anatomy very difficult for the surgeon to deal with. And if you're not confident there's a very high risk of you nicking one of the bile ducts or uh, one of the ducts in there. And that is a whole another complication. You have to send them to like a specialist, er, patio, er, biliary center loads of, er, niche procedures that would then need to be done. So you, you don't wanna do anything risky. It's actually quite a difficult operation even though they're very common. Um, but yes, so the main reason it's not option B is because you're not thinking about the other things like fluids and pain management. All right. So, very quickly, if there is, or are gallstones in the gallbladder, cholelithiasis is the word. Um, so again, similar to diverticular disease, learn all the different definitions here. It will be very, very important if you have the presence of gallstones plus it's actually causing the pain. Um, so you get colicky pain, some pain comes and it goes and it's often associated with eating fatty foods. So, if someone comes in with this right, upper quadrant pain and they say the pain comes and goes. First thing I ask is, does it often come on after you've eaten like a fatty meal or when was the last time you ate a fatty meal? Er, cos they're more likely to prescribe some sort of association with that. Um, if they have presence of gallstones with cholelithiasis, plus they have inflammation slash an infection, then it's acute cholecystitis and that's when you get inflammation and infection of it. Um, remember you don't get jaundice with this, you get jaundice if there's acute cholangitis because that is when you have an obstruction in the ducts in the bilary ducts. Um And that's what causes your jaundice, but just inflammation of the gallbladder does not cause jaundice, but it does cause pain. It does cause inflammation slash infection. The investigation of choice, you do an ultrasound, the ultrasound can show you if it's got cholecystitis. Um and it shows oppressive gallstones, but again, it's not very, it's not as accurate as um an M RCP. So an M RCP will show you the gallstones a lot better, but also act abdomen is very good as well. It can at showing the cholecystitis. So if you were, you kind of do a step wise investigation, so you can do act abdomen if you're suspecting cholecystitis, but that won't show you the gallstones. So you can then also do an ultrasound on the top to confirm that there are gallstones in there. And then if the gallstones don't show anything, but you're still sure there's probably stones in there, then you do an M RCP. All right. So that's really important if you're not suspicious that it's cholecystitis. So there's an inflammation or infection, you just think it's bitter colic. So there's pain that comes and goes. Then you don't need to worry about act abdomen. That's just to see the cholecystitis. See you can, then all you need to think about is the gallstones and then you do the ultrasound, if that doesn't show you do the M RCP. All right. So that'll be important, really important for your example, but really, really important clinically if you remember that. Um, so yeah, management wise, if it's just presence of gallstones, it's just an incidental finding which is weird cos you wouldn't do like an ultrasound there or an M RCP unless you're suspicious of that. But if you, that would just be an incidental finding, so you don't need to manage it. If the patient actually actually describes colicky pain, pain that comes and goes. There's gallstones are misbehaving, they going in and out of the, of the neck of that er, gallbladder, then to make sure there's no complications down the line and also to relieve the patients symptoms, you just do a cholecystectomy down the line. So an elective cholecystectomy, if they have acute inflammation, you can do a cholecystectomy within a week. Um, obviously, if they're not really on well, they're not like septic or anything. Otherwise you wait. Um, wait, for the inflammation to settle on you again. You just do it down the line, but in the acute phase you need to give analgesia fluids if they need it, if they're like vomiting and a antibiotics. All right. Cos that's the minimum, but then you, you might do AAA surgery there and then if not, you wait a bit further down the line electively if there's a gallstone in the common bar d that's now called choledocolithiasis. Ok. So another annoying word there. Um But yeah, if you then have that, plus you have an infection, that's now a se cholangitis. All right. Um An E RCP is the procedure of choice to uh to resolve that again, Mr Ultra, you do the same thing. So ultrasound, see if there is a stone there. If that doesn't show it, then you do the M RCP. And then, so those are your investigations and then E RCP is an intervention. So then that would be the next step if you, if you have uh seen ascending cholangitis there and there's, there is a clear obstruction. Remember you're also looking at the bloods as well. So in obstructive picture, you see AP and GAMMA GT are raised and also bilirubin is raised. Uh So if you also see those on the bloods in the, you're sure that there's some sort of bile tree obstruction um management. Yeah, we've already discussed with ascending cholangitis you can do in the LCP. But again, the baseline, giving them fluids, giving them pain relief and IV antibiotics and ascending cholangitis. If that, if you see that in a patient it's very severe. Uh, so you definitely need to keep them in, really monitor them, give them IV antibiotic cos, that's a lot scarier than cystitis. Er, really nice table summarizes everything. Um, and differentiates the 34 conditions, you can take a screenshot of this, but again, slides would also be up. All right. And that's it. So that rounds off the presentation before you all leave. I would really, really appreciate one thing if, if you all just quickly post your emails, whoever's left it in the chat, I'd really appreciate it just because we haven't actually put the feedback slides on me all we've forgotten this week, but that way I can email you a feedback form and I really, really appreciate it'll take you like 30 seconds to a minute to fill out. Um It helps me a lot for applications and whatnot down the line. Um So I'll wait a little bit if you guys could just quickly post your emails, if you're still there. That lovely, thank you. Callum anyone else, anyone still awake? Family as well? Perfect. I hope that was useful. Sorry for taking so long as well. But um quite a few important pointers there that I wanted to highlight, which might take a bit longer. Lovely. Thanks so much, everyone, us as people. Cool. Thanks. So much everyone I'll I'll send you an email out for the feedback, so I'd really appreciate that. You're very welcome thing. Alright. All the best everyone. Good luck.