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Um, hi, everyone can, can everyone hear me? Am I clear? Oh, wait. Okay. So I think we're alive now. Hi, everyone. Um Can anyone hear me? Is my audio? Okay. Leave something on the chat if you can if you can hear me? Yeah, I think we're live. Is anyone? All right, just to put anything in the chart just to say that confirm that they can hear us? Yeah. Mhm. Hmm. Okay. Give me a stick. Okay. All right, thanks Beth. Um Can you see, can you see the screen? Okay. Cool. Okay. So we'll give it a few more minutes before we start but um this is just going to be a chill session. So it's gonna be run by me and Josh um you know, just sit back, have dinner or whatever if you're fasting, you know, just just sit back um and chill but there are going to be poles that you can answer the questions with. Uh and if you do have any questions, just just shout out in a chat. Okay. We'll give it a few more minutes for um sort of more people to join and then we'll just get started. Thank you. Yeah. Mhm. So there's a few more people joining. So we said, yeah, we're just gonna give it a couple more minutes just to see how many just to give people a chance to get in. Um And then you will start. But yeah, like look man said it'll be very chill. Um So they'll just be, it'll all be done via poles, just give it a go even if you, even if you're not sure it's quite, quite good just to try like commit to an answer and, and see, but we don't see what individual people put and no one else can see. So is purely anonymous. Um Lakshmi said she can't get video or audio. I'm not sure if that's, is that, is that a problem with us? Mhm. Um What about everyone else? Can everyone else hears just to see if anyone else can hear us? I'm thinking is you may be on safari. I don't know. Um Is anyone else just able to pop in the chart whether they can hear us or see us? Yeah. So Sabina can here's um yeah, so like, I mean it could be something with your, your audio settings maybe. Yeah, if she can't hear it, let me just put in the chart. Uh Okay. I think we've got a decent turn up. Um Should we start? Okay. All right. Okay. So, hi everyone. Um my name Folkman and I've got Josh here with me. Um and we're to finally your medical students from the University of Manchester and we're just prepared um, sort of a series of teaching sessions on surgical topics. Um is we're trying to make it as relevant to undergraduate exams as possible, especially since, you know, you guys have potentially the MLA is coming up next year um in your own finals coming up in uh at the end of the year, if you're here for you, probably you might have MLS next year. So this is going to be the upper gi and hepatobiliary session. Okay. It's our first session. So we'll try to make it as good as possible. Um And like I said, it's just, it's just gonna be polls, um you know, interact with it, even if you don't know the answer, just interact with it. Your names are going to come out in the polls. Any questions, um You can just type in the chat or you can just mute yourself and you can just talk to us. Okay. So overview of the session is going to be 20 mg Q questions. Well, it's actually 18 for this one because I didn't want to overrun and they're taken from past medicine. It covers major themes. Like I said before, there's gonna be polls and we're going to try and replicate actual exam situations. So you'll only have 80 seconds to answer the question and then we'll discuss it together and then at the end of every question we've got learning points to do. Okay. So let's just jump straight into it. Here's the first question you have 80 seconds. Oh, whoops. Oh, gosh. Wait, Josh, can you create a bowl for the first one? I think the, I think the first one is being put on the track. I think it's okay. Yeah. Yeah. Okay. Okay. Cool. Yeah. Okay. You've got about 10 seconds left. You haven't put the answers in, just guess that's what I do. Okay. So the answer was acute cholecystitis so well done to 50% of you. Um So yeah, so the answer is called cystitis. And the reason is, um uh, so let's talk about what acute cholecystitis is. Okay. So, from the prompt, you can see it's a 45 year old woman presents with to the emergency department with intense being the right upper quadrant, uh and is Pyrexic and she's tachycardia and take it Nick. So what is acute cholecystitis is basically inflammation of the gallbladder and it's usually caused by gallstones. So it's that, that thing right there. Okay. So this is a typical history of acute cholecystitis um in uh in anyone. So they tend to have right upper quadrant pain and they're systemically unwell. So the prompt did say she was pyrexic. She's got tachycardia. Um And there's also a specific sign for, uh for this, does anyone know what the sign is called? Type it in the chat if you know? Okay. Well, it's called it's called Murphy sign. Yeah. Correct. Well done by in. So it's called Murphy sign. So, what's Murphy sign? Actually? What do you see in Murphy sign type in the chat if you know, if not, I'm just gonna, okay, that's fine. So it's in spiritually arrest on pal patient of the right upper quadrant. So if you tell them to breathe in and then you, you press the right upper quadrant, they'll just suddenly stop breathing because of the pain. So that's what you find in Murphy sign. Okay. Quite a few people answered a um what was a an acute college itis? Now, we'll get to why that isn't the case uh in later questions. So we'll move on but well done for the first question. OK. Um Yeah, well done by then. Yeah. Correct. OK. So let's move on to the next question. Okay. You have 80 seconds to do this. Thank you. Okay guys. 10 more seconds have a guess. Okay. So the answer to this one, it's biliary colic. Okay. So, um quite a few of you got this one correct. Um And you know, the the 22 common conditions that people off that people often sort of get confused is biliary colic and acute cholecystitis. And the only difference between the two is that biliary colic doesn't have systemic upset. So there's no, they tend not to have a fever um as mentioned in the prompt, you know, it's radiates to the shoulder um, again, pain in the right upper quadrant as well. Um, and it's recurrent pain, okay, a little bit on biliary colic. So, biliary colic is usually caused by gallstones and gallstones are usually formed when bile in the gallbladder, saturates and it becomes really concentrated. So, bile is full of cholesterol, um, calcium and a lot of stuff that can form stones. So, what happens in biliary colic is that these stones impact at the, um, at the neck of the gallbladder, near the cystic duct and the contraction of the gallbladder against the impacted neck is what causes the pain, but there's no inflammation. So that's the only difference between biliary colic and acute causes like this. Okay. Um So yeah, so going, yeah, so it commonly presents with right upper quadrant pain after meals with nausea and vomiting, especially after fatty meals. Does anyone know why? Especially after fatty meals type in the chat? If you know, well done by then? Yes. So bile is needed for fat, digestion. Bile emulsifies fats. So, if you eat something fatty, the uh gallbladder will be stimulated to release bile. Um, so yeah, it basically stimulates uh, something called cholecystokinin in. Um, it's a bit technical, you don't really have to know this, but it's just general information for you guys. It classically radiates to the interscapular region. So, you know, biliary colic or acute cholecystitis, it radiates to the interscapular region. Does anyone know why? Well, it's because it's referred pain from the diaphragm. That's, that's why, that's why it's, sometimes you can get inter scapula pain. Well, Bryan, you, you know your stuff. Very good. Very good. All right. Hopefully that's clear. So let's move on to the next question. Okay. 80 seconds. Oh, I should, I was asking something. Hold on. Uh All right. 10 seconds. Okay. So the answer to this one is ascending cholangitis, correct? Uh 66% of you got it so well done. Um So let's talk a bit about ascending cholangitis. Okay. So senna college scientists basically what it is. It's inflammation of the biliary due to a blockage. Okay. So it's the oval circle, I circle on the left. Um um So anything can cause the blockage, anything that can cause a blockage of the biliary tree can cause ascending cholangitis. Essentially. Uh most commonly stones and other stuff is like a cholangiocarcinoma, which is basically just a cancer of the biliary tree that blocks it. Okay. So when you block the bill, you tree, there's a chance for infections and will infect the entire biliary tree. So how do you differentiate this from acute cholecystitis, for example. So the only difference is that this one actually causes jaundice. So there's a, there's a uh recently revealed it, but there's a triad that's, that's, that's, that's called Charcot is try it. Well, I I accidentally revealed it okay. So it consists of right upper quadrant pain fever and John is if you see these three in a in an exam question, it's almost always ascending cholangitis, right? Um Yeah. So there's also something called Reynolds Pen Tad Bayan. Do you think, you know, you might know what this is or anyone else buying seems to know about get them again. I don't think this is very relevant. This is just extra stuff for um for your own knowledge, humility, uremic syndrome. Not really. Is that what you're thinking? Humility Remix syndrome? You might. Well, Reynolds Pontet is basically yes, correct. Beth, it's hypertension and confusion which is basically just ascending cholangitis progressing to sepsis. I don't know why they give a completely different name for it. I think it's, it's not really worth knowing but just know Charcot's try it for now for ascending cholangitis. Okay. All right. So I should ask about colonic, the Asus column with ISIS. Yeah. Yeah. No, no, that's a valid question. So I think that was the one before the one where it was about biliary colic. Um But yeah. So from what I understand, Kahlo life, I ASIS is just like the correct proper term for like gallstone disease. Um okay, same as just normal gallstones and you'll see normal gallstones commonly referred to as biliary colic. I think biliary colic, strictly speaking, is the pain that you get from gallstones. Um But it's essentially the same thing I would just think as gallstones, biliary colic. Kahlil, if isis is all under the same sort of thing if that makes sense. But yeah, good question. Nice. Even I learned something. All right. So that's, we've basically covered biliary colic, acute cholecystitis and ascending cholangitis. Okay. And they're all very similar. Um And I've summarized it in a nice table for you guys. Okay. So biliary colic has right, upper quadrant pain's usually colicky worse after fatty foods, acute cholecystitis, right, upper quadrant pain and there's usually systemic upset as well. You can also see Murphy sign Collinge itis is right, upper quadrant pain, fever and systemic upset and then you can join this as well. Okay. And as I mentioned before, the reason they have joined this is because there's blockage of the common bile duct and that's why bio can't escape and then all the bile gets stored up and then that causes jaundice. All right. Yes, I guess. Yes, I should. I guess you could say Reynolds Pantech is basically billary sepsis because they've got confusion and hypertension, which is basically signs of sepsis anyway. Um Yeah, I think, I think that that's how I I would look at it essentially. All right. Um So hopefully that makes sense. So here's a question for you guys. What's the first form of imaging for right upper quadrant pain when you're subset, when you're suspecting any of the three we've talked about. It was the first imaging you do. No. Uh You lot, you lot are good, very well done. Um Yeah, so you do, you do an ultrasound? Okay. And the reason you do an ultrasound is because it's quick, it's easy. It's cheap and it can detect a lot of things. Um, and it can rule out a lot of stuff as well. So you can detect the presence of gallstones and sludge. Uh, you know, as an etiology for the causes of these things, you can see gallbladder wall thickness and if it's thickened, it means inflammation might be likely. And then you can also detect bio duct dilatation in some cases. So it could indicate a possible blockage of the biliary tree. So always do ultrasound. If, if a question says, what's the next, what's the next best thing to do? And there's no imaging done yet. The answer is usually ultrasound. All right. Right. So hopefully that makes sense. Let's move on to question four. Alright. 80 seconds. You might just have to move on to the next page. Look one in there. Yeah. Yeah. Yeah. So this one has two parts. So I'm gonna give a few more seconds to read this one and then I'll move on to the next part. Yeah, I'll give a few more seconds for this one. If anyone needs to, to go back and see the initial one, let me know if anyone needs to see the first part of the question. Okay. I'll give 10 more seconds. Okay. All right. So I'm just gonna move on. Okay. The answer was endoscopic retrograde cholangiopancreatography. All right. So, going back to the prompt, you can see that the patient has upper abdominal pain. He's got a high temperature sort of his technique, Arctic. Um And from his blood, you can see that his Billy Ruben is raised. So this is a classic Charcot's triad that you've seen here. So it means the patient has ascending cholangitis. All right. And I'm pretty sure a lot of you figure that out. They did an ultrasound, see. So the first thing I did was an ultrasound and then they saw dilated intrahepatic and extrahepatic ducks, which means there's an obstruction and multiple hyper echoic spheres within the gallbladder, which means that it's caused by gallstones. All right. Um So why would we do an ERCP instead of all the other things? So, do you know what does anyone know what an ERCP is? First and foremost? What does it do? Okay. So, don't worry about it. We'll just talk, we'll just talk to it. Okay. So, patient is presenting with Marcos triad ultrasound scan was already done. So, the next step is E ERCP. So M R C P, a few of you chose M R C P as well. Um Yes. Uh correct Sabina. So M R C P is the same as ERCP. It's both, it both visualize is the biliary tract. Essentially MRCB is basically just an MRI scan of the biliary tract. That's it. And an E ERCP um is basically this, it's a scope. It's basically a scope that just goes all the way down um to your pancreas and your biliary tree and then it injects a dye into your biliary tree and then you take an image of it and you can see all sorts of stuff. And the reason you do an E ERCP and not an M R C P is because an ERCP is both diagnostic and therapeutic. So you can see what's going on and then while it's there, you can just remove the stones as well. There's this little thing called called baskets at the end of the ERCP scope that can actually pull um pull the stones out. So if you're uh suspecting ascending cholangitis, you do an ultrasound and you see there's debilitation, you see that there's a possible obstruction, you just go straight to ERCP, right? It's gold standard after you've done an ultrasound. And if you find that they're having recurrent ascending cholangitis, you can even put a stent in and then it prevents any further ascending cholangitis. Some people do do an MRCPI before they do an ERCP. But for exam question purposes, it's always ERCP. It's both investigation and treatment for ascending cholangitis. All right. Does that make sense again? Just pop a question if, if, if I'm going too quick or if, if you don't understand anything. All right, I've summarized a nice little table for you guys as well for right up quadrant imaging. So, biliary colic, everything uses ultrasound initially and then after ultrasound, it depends on what you're trying to look at. All. Right. Again, it's M R C P usually for biliary colic and acute cholecystitis. Um, but for Colin gi tissue just go straight to ERCP because it's both diagnostic and therapeutic. Okay. All right. Question five. I'm opening the polls again. Right. 80 seconds. Gents and ladies, Aisha, you're talking about E ERCP for ascending cholangitis. It is definitive um is definitive treatment for both investigations and treatment force any college itis. Oh, wait. Oh, sorry. When the question says next best with M R C P be appropriate. Um No, I still think you would do ERCP straight away. I don't think you would. Well, for questions purposes, I don't think you would do M R C P. It'll be kind of harsh as well for them to ask, I guess. But if it's ascending cholangitis, just go straight to the ERCP. It's what I'd say. What? Okay guys. 10 more seconds. It's a classic nice guideline type of question past Metal loves these types of questions. They just quiz you on the nice guidelines. Okay. And I can see from the polls, this has been quite equally split between B and C. Now it is what the answer is one of those two things. And sadly, for 50% of you, the answer is actually c and again, this is just a classic, nice guidelines thing. You just have to remember this. Um, it used to be once inflammation has subsided, but I think like recent over the past years, it's become a leprosy. Laproscopic cholecystectomy within one week of diagnosis. Regardless of how bad it is, it has to be within one week. Okay. Um, conservative management might not be the best idea simply because the patient is systemically unwell. Okay. And you don't want this to, um, you know, progress to full blown sepsis. And in terms of open cholecystectomy, no one does open cholecystectomy is nowadays okay. So well done. Um It's just a short explanation. Patient is presenting with acute cholecystitis um because you know, they've got fever and they got right up a quarter of pain and the management of acute cholecystitis. Now, there's one thing you give before lepra laproscopic cholecystectomy and that's IV antibiotics. Okay. So you always give usually in the prompt sales, they'll say they started on IV antibiotics. So even in this problem, she's immediately started on intravenous antibiotics. Okay. So you always give IV antibiotics first and then you do a laparoscopic cholecystectomy right? Within one week of diagnosis. Okay. All right. Next question. 80 seconds. Alright. 10 seconds. If you don't know, just give a guess. All right. So, um, well, then the answer is b elective laparoscopic cholecystectomy. All right. So let's, let's have a look at this question. So, what, what is she actually presenting with? All right. So she's got right pain in the upper right hand side of her abdomen. So that's right, upper quadrant pain. Uh past few months, she doesn't have a fever and she doesn't have any jaundice. So this is biliary colic right here. Um And for biliary colic, especially if it's recurrent is the same as acute cholecystitis, except it doesn't have to be done within a week. So it's an elective laproscopic cholecystectomy for biliary colic, but it doesn't have to be done within a week. It can be done whenever it's suitable for, for the patient. Essentially elective ERCP, as I mentioned before, it's only done for ascending cholangitis. You don't really do ERCP for any other stuff. M R C P isn't a management, it's just an investigation and they're asking for definitive management of this um percutaneously cholecystostomy. Now, if you guys don't know what that is, just go by the name if you've heard of a Nephrostomy and if you've heard of like um um a gastrostomy, it's basically the same thing except it goes into your, into your gallbladder, you know, it's to drain something else. So usually it's plus, if there's puss in your gallbladder, they can do a cholecystostomy. But again, this probably wouldn't come out in any of your questions. It's kind of harsh and it's not really urgent for an urgent ERCP to be done. Okay. Um Josh has dropped the feedback form, please fill it in if, if you can, um we'll give the slides up. At the end of the whole thing, once you filled in the feedback form, okay. Um You don't have to fill it, you know, you can feel it in at the, at the end. Okay. Yeah. Uh Definitely Oliver just ask for the feedback from. So I've just popped in now for, for you Oliver, but for the rest of you do, if you plan on staying for the rest of the session, don't worry about filling in for the moment. But yeah. Right. So quick explanation. Patient's presenting with brilliant colic management of biliary colic is elective laparoscopic cholecystectomy. It doesn't have to be within one week essentially. Okay. I've got a nice little table as well for you guys for the treatments of the three conditions we've talked about before. You can have a look at this once, once we're done with the questions, but I'm just being wary of times. I'm just going to be a bit quicker on this one. Okay. So 80 seconds from this one, I'll just drop the polls 20 seconds and that's time, right? So this is one, this is one of those questions where you just, you even know it or you don't. But it's very simple ascending cholangitis. Most common positive organism is always equaling, it's always equal. I uh don't ask me why. I don't actually know why. Maybe it's because E coli is one of the most common um sort of gut bacteria available. Could be that um but for exams say, just remember ascending cholangitis, most important organism equaling again, I haven't actually seen this come out in exams very much, but it can be quite important to know. All right. So equalized common positive organism force and ecology itis other common conditions caused by equalize like UTI S and other gi infections that can cause diarrhea. Okay. Right. Moving on question. 8 80 seconds. Yes. That's correct. Sabina. It's also the most common cause of UTI S. It's almost always equal life for UTI S. All right guys. 20 seconds. Exam piece, exam piece. All right. So that's quite a split between this and I can understand, I didn't know the answer to this question beforehand as well. Um And again, it's just one of those things where you just sort of have to know. Um the answer is, is Chron's all right. Um So Chron's disease can cause um uh is a risk factor for what this patient has, which as you can see cramping, right, upper quadrant pain worse after eating fatty meals, classic biliary colic. But why, why, why is Chron's a risk factor? Um So it's because I'm actually reading this right now because I, I actually don't remember this as well. So the terminal I re um okay. So Terminal Island is the part of the part of the GI system that's most affected in Chron's. Okay. And the terminal ileum is the part that's most involved in the metabolism in the metabolism of bile salts. So, if bile salts aren't metabolized, you get the same problem as before. Remember, bile salts becoming too saturated, too concentrated and that's what's causing all the bile stones. Okay. The others her age. So in terms of her age, she's actually pretty young. So you need to be 40 or above for it to be a risk factor, her ethnicity as well. Um I think um, so it's not African women who are at risk. It's Caucasian women who are at risk. Okay. Um and primary biliary cholangitis and primary scorers in college itis both just have, have very little to do with, with biliary colic. Um risk factors. Okay. Um So yeah, so she's presenting with biliary colic. Uh I've mentioned this before. Yeah, excessive bile salts. Um okay. So these are the other risk factors. Uh okay. So hydra has told us patient's with Chron's are an increased risk of renal stones as well. Uh Oh, well, it got it kind of makes sense. I guess it increases your, your cholesterol and all the calcium levels as well. So good tip. So other risk for gallstones. Remember the four f fat female fertile 40. Okay. So if they're overweight, they're female. If they're pregnant. If they're over 40 these are all risk factors for gallstones. Okay. Other risk factors as mentioned below Chron's disease, diabetes and rapid weight loss as well. Um Okay. So just remember the four Fs for risk factors for gallstones. Well done. Now, let's move on question nine. Uh, so I know it's in bullet points but just, just pretend it's a two E right, 15 seconds clock is ticking. Have a guess. Have, I guess if you haven't answered yet? Okay. So again, this is just an anatomy question. Um, you know, you need to know the anatomy if to sort of answer this question and, you know, it sort of makes sense if you think about it. So let's just go through the question really quick. So, right, upper quadrant pain, um signs of jaundice uh and patient denies pale stools or dark urine. Okay. Oh, no, clinical signs of jaundice, sorry. Um And no pale stools or dark urine. Okay. So that means it's not a blockage of some sort. Ok. Um Extramural compression means that something is just compressing on the biliary tree from the outside. It could be cancer, it could be something else. It's usually cancer in this case. Um And the question is, where is the most likely location of the lesion? So which of these if blocked would not cause joint is, and in other words, which would not block the flow of bile? Okay. So that's, that's basically what this question is asking. Um And the answer is cystic duct, okay. And the reason is, is the cystic duct um is because we need to have a look at like the anatomy of this. So see the cystic duct basically just connects the common bile duct to the gallbladder on the left and bile can still flow through the common bile duct. Um And as long as it can flow, it will not cause jaundice. Essentially the other stuff on the on the questions such as the employees elevator, the sphincter of oddi common bile duct, common hepatic dot All those will block the flow of bile into the gi track. So bile needs to flow into the GI track so they can be excreted. So if any of these are blocked, it will cause jaundice. And usually it's something like pancreatic cancer. Okay. If you see painless jaundice in any patient, it's immediate red flags for pancreatic cancer. Okay. And just to hit home, the cystic duct is the only one that doesn't block the flow of violent to the gi tract, which is why that's the answer. Right. Right. Next question. Question. 10, 80 seconds. Okay. Yeah. All right. 20 seconds, 10 seconds have a guess. Okay. So 71% of you said serum lipase. So what's what's going on in this patient? First and foremost, if anyone can type in the chat. Yes, sir. So this patient has acute pancreatitis. All right. She's got intense pain in the epigastrium radiating to the back, heavy history of alcohol. She drinks one glass of wine per day. This is again a classic, classic image of someone with acute pancreatitis. And you're right. The answer is serum lipase So the, the key is them asking which is most likely to yield the diagnosis. Um So the others, the others are good at ruling out other stuff. But serum lipase would be the one to really hit home that it's acute pancreatitis. Does anyone remember what about the serum lipase that points towards acute pancreatitis? Or what, what, what the range is if you guys remember? Yes, correct. Um Elevated upper border of normal is what I would say. So there's, there's usually a range right? For serum lipase. So it's the upper border times three. So that's, that's what makes what will make you think of your pancreatitis. It applied to the same to Emily's as well. Okay. Um Yeah. Um like a time there's usually three times the upper limit of normal. Okay. So what about chest X ray and abdominal X ray? Do you just not do it? Well, you can, you can, it's not helpful in diagnosing but it can rule out other causes such as an obstruction or a perforation. All right. But usually if they ask for like diagnosis is usually like pace or MLS essentially. Well, then let's move on. Uh So here's the summary of acute pancreatitis symptoms. Yeah. So there's severe epigastric pain reliever, back, vomiting, common may reveal epigastric tenderness and low grade fever. Uh I'm pretty sure you guys have heard of Colin Sign and Great Turner Sign. It's very rare. Um You don't really, you don't really see often honestly in wards. Um, and a history of alcohol abuse is very, very common. All right. Okay. So I've got a picture here. Which one is Great Turner sign and which one is called in sign? Just for the laws? Have a guess. Well done. Well done is correct. So how I remember it c looks like a belly button. So peri umbilical bruising. I don't know. I, I just associate see with the, with the belly button. So periumbilical and then the other which is flanked discoloration bruising is just Great Turner's, that's, or at least that's how I remember it again. Very rare for, for a question like this to come up and I think Josh has something to say as well. Yeah. Yeah, I'm just gonna put the feedback form in, in case anyone was leaving soon. But yeah, but I know there's a lot of people that use the same way to remember Colin and Great Earners as you. Um The way I remember it is just slightly different to might help some people is Collins. So you only have one belly burn or umbilicus and Collins is only one word, whereas Great Earners is two words and you have to flanks. Um So yeah, that's, that's another way in case that helps. But yeah, it's niche knowledge this so you don't really have to worry too much. But if you do know it's quite nice just to know. Um But yeah, so I'm just gonna pop the feedback form in the chart you don't have if we've got another, another couple of questions. So we'll go through them. But for anyone that needs to leave at eight o'clock, no problem, I'll just put the feedback form in. So if you can fill it out before you leave, then that's very much appreciated. But yeah, thank you. Yes, please fill in the feedback forms we survive on those. Anyway, let's move on to question 11. Okay. 80 seconds. Yeah. Uh All right. 10 seconds, guys. Okay. Right. So that's quite an even split in the answers. Um And this is, this is a tricky tricky, tricky question. So, from the prompt, we can see that she's got acute pancreatitis. All right. So she's got pain radiating to the back, sudden onset, upper abdominal pain. Um She's experienced pain uh similar in the past and it's particularly worse after eating as well. Um So pancreatitis can, can be worse after eating. And the reason is because pancreas pancreatitis produces eggs, a crime enzymes to digest food, which is why it hurts after eating. Okay. So, uh just a short explanation on that. And they've done in Emily's, they've already done an Emily. So they've confirmed that it's acute pancreatitis. So, what's the question is asking, what's next? What do you do after you've done in Emily's aura like piece? And the answer is a trans abdominal ultrasound. Okay. And I can understand why you might want to do the other stuff. So an M R C P uh can be helpful in this case as well. But it's just because an ultrasound is just that much quicker and that much cheaper. And in the early stages, it can give a huge clue as to what's causing pancreatitis. And usually it's gallstones, gallstones causes pancreatitis as well. Why would it not be a good idea to do a contrast, enhanced CT abdomen on this lady? Can anyone tell me the chat? Well, yes. And she's also got CKD. So best not to use contrast in a patient with CKD essentially. Um, yeah, exactly. Exactly. So there's a quick explanation of the, of the previous one patient is presenting with acute pancreatitis. All right, we've established that what was done. A serum Emily's was already done. So, what's next? You do a trans abdominal ultrasound? And that's to look for the etiology of the pancreatitis. What's causing the pancreatitis? Ultrasound. Quickest thing. Easy, simple, cheap. You can do it. Okay. So, yeah. Well, the nutrition, yeah, it's CKD. So in acute pancreatitis investigations, the first step is to confirm the pancreatitis. Okay. So you either you either do an amylase or lipase along with the other bloods as well, you obviously have to rule out stuff like infection, but you do an amylase and lipase first to confirm the pancreatitis. And once it's confirmed, the second step is to find the etiology and that's usually with an ultrasound scan, if you can't find anything with an ultrasound scan, that's when people tend to move on to other stuff, they can do an ad dose CT without contrast or they can do em are CPR ERCP to look for other signs or etiology. Yeah. Well done Aisha. Yeah. CKD. Okay. Good. Next question. Question 12. Again, this is just sort of like a if you know what, you know it sort of thing, 80 seconds, I'll make, I'll make this 60 60 seconds. Alright. 10 seconds. Okay. Let's get a move on. Um So yes, it's evenly split between lipase and amylase can. I mean it tends to be those two for acute pancreatitis. Um C peptide is actually for insulin. So people use c-peptide if they want to see if someone is, I think it's used to differentiate between. Was it type two? No? Well, basically cpap C peptide is, is high if you produce insulin. So you use that to differentiate between types of diabetes. So it's not C peptide trips in and Trypsinogen. I forgot what those are for. Um um Well, if anyone knows, please please type in the chat but the focus of the question is between lipase and amylase. Okay. Um Yes, yes, that's, yeah, that's the one by. Yeah, well done. All right. Uh Again, if you guys have any bits of information to share with the rest of the group, please do. Ok. I don't know everything but it'll be good for the rest of the group to know as well. Okay, anyway, back to the question, um emulates versus lipase. It's like base, okay. I don't like, it's just more sensitive and more specific. Um And here's some, there's some like papers on it as well that says lipase is more specific and more sensitive. Um Yeah. So it might, it might have got like a nice explanation of c-peptide as well. But yeah, so lipase is technically more specific and more sensitive. But I've never seen a question actually, comparing between extends. It's just something nice to know. Okay. So let's move on question 13. Here we go. Let's do 60 seconds for this one. All right. 10 seconds. Just give it a guess. Okay. All right. So what's going on in this patient right here? So she's got a history of biliary colic. She's got severe abdominal pain and nausea. So you could be thinking of two things. She could be having another biliary colic or she could be having acute pancreatitis as well in this case because remember acute pancreatitis, one of the etiology is gallstones. So she's got a history of recurrent gallstones and a hint is within the answers themselves. You can see one of them has low calcium, okay. And again, this is one of those things where it's just, it's just pattern recognition honestly. And the answer is in fact, the first one simply because of her hypocalcaemia. Okay. So, hypercalcemia can cause pancreatitis. But hypocalcaemia is actually an indicator of severe pancreatitis. Okay. So, if you're suspecting pancreatitis and you see they've got low calcium, it could be an indicator that it's severe. All right. Um, other signs of like severe pancreatitis or measure or severity of pancreatitis. You use something called the Glasgow scale. There's a lot of scales out there using, using Glasgow. Um, why calcium low and pancreatitis? That is a good question is a good question. I'll try to look it up. That's a great question. You know, a great question. I'm not sure. That is a great question. Yeah, look it off and see if I can get an answer for you. Yeah, Josh will look it up for you. Um We'll try to find the answer. Um It could be because it's related to the formation of the gallstones. I don't know, Josh is going to look it up. Um But yeah, anyway, on the Glasgow scale for pancreatitis, uh there's a bunch of other stuff in here. Again. I don't think you need to remember any of this. Um Just remember that low calcium is an indicator for severe pancreatitis. All right. Um Yeah, they use Glasgow a lot um for, for the scales for some reason, there's like the Glasgow Coma scale and like the Glasgow Blatchford score for some reason, it's all it's all created in Glasgow. And I don't know why said no fish, fish vacation in the pancreas during pancreatitis ah, interesting. What is? Oh, shit. Ok. Process in which triglycerides are combined with strong based upon fatty acid metal salts during soap making process. I guess so. I guess so. Yeah. But just remember low calcium, severe pancreatitis. All right. That's all you need to know for exam purposes. Let's move on. Um. All right. Question 14. Let's get this, uh, 80 seconds. We'll make this 60 Glasgow Emery. Uh, can you clarify Aisha? What do you mean? Um Yeah, I think it's the Glasgow Emery. I think it starts to the opening to that, that score. Okay. Um I looked at the calcium thing. I can't seem to find a correct, like an easy answer for her. Um, but there's a few papers now that, but yeah, sorry about that. All right guys. 10 seconds one. Okay. So let's talk about what's going on in this patient. So she's got acute abdominal pain, no history of loose stools, constipation as you're formatting, um, pain radiating to the right shoulder and the back. She's also got an elevated lipase more than three times the upper limit. So this is a coupon keratitis. The question is simple. What's the next appropriate step in management in terms of her nutrition? Again, this is something you either no or you don't. And I can understand it's kind of intuitive to keep her near by mouth and give IV fluids as necessary. You know, she's in a lot of pain. Um, you know, she is not, she is nauseous and vomiting, but it is important to try and encourage nutrition orally. Um, that's just the way nice has recommended. It always encourage feeding through, through the oral, oral route before you do IV. Um, if they're vomiting and they really can't stand the food or they can't stand nutrition orally, uh, then you can think about giving IV fluids. But yeah, for acute pancreatitis always try giving food orally first. Okay. It's just better for the patient and it's, it's, it's, it's better in terms of recovery for the patient after the episode of acute pancreatitis essentially. So, yeah, if they can't tolerate all our old, then you do N G tube and if N G tube doesn't work, then you can do IV fluids. Okay. Um So for acute pancreatitis, the management is mainly just supportive, give IV fluids. Um you give urine output, uh IV fluids plus urine output monitoring. You need to make sure they're very, very well hydrated because of all the vomiting that could be severely dehy, hydrated analgesia. There in a lot of pain, always give them IV opioids and for nutrition, always give them by mouth. Um always try orally first. If that doesn't work, do N G tube and if an N G tube doesn't work, then you can do parenteral, full, parental nutrition if needed and then is to treat the underlying cause. So if it's caused by gallstones, then you treat the underlying cause by doing an ERCP. Okay. Right. Let's move on. We've got about three more questions to go. Let's see how many people are still in the chat. 23. Again, if you guys have to leave, I'm really sorry that it's overrun, we'll try to run it within time next time. Um Okay, but if you're, if you're still sticking around, we've only got three questions left. Okay. Let's go. Question 15. I'll move to the second one in a bit. I'll just let you guys read the first prompt first. Mhm. Okay. I'm going to move on to the X ray if that's okay with everyone. Okay, someone's already answered, but I haven't given the options yet. Okay. I'll give the options. Let me know if any of you want to see the X ray again. All right, I'll give 10 more seconds. I appreciate. It was difficult to see the X ray, especially on the small screen. So don't worry about it. Okay. I'm just gonna move on. All right. So the answer is chronic pancreatitis because do you notice on the top right corner of the, of the X ray here, you can see the pancreas has small dots of calcification around it. Uh And it's one of those things where when you see it, you immediately know what's going on if it's chronic pancreatitis and they see and they show you an X ray of something like this and you see this is almost always chronic pancreatitis. That's calcification of the pancreas right there. Okay. Um, going back to the prompt itself, you can also see that she's got abdominal pain rating to back for the past year. So it's not acute. It's been going on for a while. Um, she's got, she's on calcipotriene I'll, which is a calcium or is it a vitamin D? I think it's vitamin D, uh sort of cream. So that can increase sort of calcium levels as well. She's lost 3 kg. Uh and she drinks an excess amount of alcohol as well. So these all point towards pancreatitis and it's the chronic pancreatitis because it's gone over a certain period. But it's the X ray that really shows um that is chronic pancreatitis. All right. Um And that's why the answer is chronic pancreatitis. Okay. So the symptoms of chronic pancreatitis is pain similar to acute pancreatitis but not very sudden epigastrium area radiating to the back is usually worth 15 to 30 minutes after a meal. And usually that's the immediate pain that you get in chronic pancreatitis is early on. But if you, if you don't do anything about the chronic pancreatitis over years, you can get both xr crim and endocrine um deficiency. Okay. Does anyone know what, what I mean by exocrine and endocrine deficiency? Can anyone tell me or, or like what's the difference between exocrine and endocrine? Okay. Ok. Insulin in trips in deficiency. And is that exocrine or endocrine a month. Yeah. Right. Correct. So, it's endocrine. So, endocrine basically means enzymes that are released into the bloodstream and then eggs Ockrent basically just means enzymes released into um like tubes. So something like the gut, for example. Uh Yes. Correct. Actually. Yeah. Exocrine. Yeah. Correct. So, exocrine deficiency causes digestive enzymes to decrease and that can cause things like steatorrhea. Uh diarrhea is basically just fatty stools. So you get pale stools that float in the toilet there really stinky. Um And it takes a long time to actually develop this uh this eggs Ockrent and endocrine deficiency. You know, it takes years and years and years. But once you have it, it's really difficult to reverse, especially for endocrine deficiency, you basically get diabetes for endocrine efficiency and yeah, chronic pancreatitis over a long run. Not great. All right. Does that make sense? So, chronic pancreatitis symptoms, pain early on and then over the course of many years, you can get exocrine insufficiency and endocrine insufficiency, diabetes and statutory A essentially. Okay. Right. Let's move on question 16. We've just got three more, three more and then we're done. Alright. 60 seconds. I'll try to finish this before. Um, the people who have to fast have to break faster. All right. Okay. Mhm. Okay. All right. So, uh let's go through what's going on with this lady right here. 65 year old male presents PGP recurrent, mild upper abdominal pain following a meal, foul smelling greasy stools Now that tells me he's got steatorrhea, probable exocrine insufficiency sounds familiar. A so he's probably got chronic pancreatitis. He's been having this drinks 80 units per week, which is absurd. Um The question is, what is the most appropriate diagnostic test? Okay. Now people answered fecal last days early on and if they were to ask, how would you measure eggs a crime function? Then yes, fecal elastase would be, would be the go to. But we're looking for a diagnostic test and the the best test for chronic pancreatitis is actually a CT scan. Okay. Um It visualizes the pancreas. The best abdominal X ray is good for initial investigations just to rule out other causes, could give a clue to acute pancreatitis as well. Um But uh for diagnostic purposes, it is ct abdomen. Okay. Okay. I'm just gonna whizz through this as quick as quickly as possible. So, patient presenting with chronic pancreatitis investigation of try just remember chronic pancreatitis diet. Gold standard diagnostic investigation CT scan. Okay. You can do an abdominal X ray and an ultrasound scan before but it's not as sensitive as the CT. That's more to rule out other causes. Okay. Let's move on to more questions. All right, let's go 80 seconds. Yeah, I won't give too much time about this. We, we literally just talked about this just now. So, yeah. Um uh the answer is fecal elastase. Yeah. Um uh Because of the because of previous things before um vehicle. Last, this is the best way to measure sort of exocrine function for someone who you think might have um, an effective pancreas over the long run. Okay. Again, this is one of those questions where you, you just have to remember it. If you see a question asking, how do you assess exocrine function? It's almost always fecal elastase serum MLS, serum lipase. Again, that's just to measure the diagnosis. Serum calcium would be good for severity as mentioned before, but it's not going to measure exocrine function. All right. Uh Yeah, I figure this is useful test whether I invite exocrine function. We talked about this. Um, so investigations for chronic pancreatitis again, you confirm it first with amylase and lipase. Oh, wait, no, you don't confirm with amylase and lipase is a question. Will it be raised in chronic pancreatitis? Sorry, will emulates and lipase be raised in chronic pancreatitis? Well, then it won't because we just talked about this exocrine function will be, uh, will be affected and Emily's and lipase are digestive enzymes. So, if exocrine function is affected, Emily's and lipase will go down as well. So, actually, yes, it will either be normal. Oh, yes. Correct. Yeah, they tend to return to normal a few days after pancreatic injury. Yeah, that's correct. So, yes. So it can be normal or it can be low. Um, um, in, in chronic pancreatitis because of the affected function. Okay. And I've again, I've, I've put all the explanations here. You can have a read through um at the end, um a little bit on imaging and chronic pancreatitis abdominal X ray can be a good initial investigation to do to rule out other other causes. But it's only sensitive for calcification. 30% of cases. CT is definitive and diagnostic. Okay. So if a question asks, uh and you suspect the patient has chronic pancreatitis and they asked what's diagnostic or what's the best management that the answer or what's the best investigation? Then the answer is C T. Okay. Uh Here are some causes of chronic pancreatitis. Chronic alcohol abuse is usually always, always the cause it can be idiopathic as well in 30%. Um And other less common causes is stones. You can get cystic fibrosis as well because if you know cystic fibrosis, um you know, thickens the mucus in the pancreas clogging it up and you can have autoimmune pancreatitis as well. But you know, these are rare, okay. Just focus on chronic alcohol abuse, usually chronic pancreatitis. Okay. Last question again. I'm really sorry guys for overrunning. I will try to make it quicker for the next one. Thank you, Aisha. Thank you for joining uh Eat Mubarak. I'm not sure if it's tomorrow or if it's Saturday. I still don't know. Uh But yeah, last question guys. Uh This one is a little bit of a multilayered question. Yeah. 60 seconds. Okay. 10 seconds have a guess. Final question. Okay. So this is one of those questions. Where is this classic pattern recognition? Okay, you see a certain set of conditions and you know, okay, this is what's going on. So you see this question and then you see a bunch of this 72 year old man presenting with neuro symptoms. Um and the key is he's had a sub total gastrectomy four years ago. Okay. So that's, that's the key. So subacute combined generation is the answer. Um And the reason for that is because of the gastrectomy. So the gastrectomy um okay. Well, let's talk about what subacute combine degeneration is okay. So subacute combined degeneration of the spinal cord is basically when certain areas of your spinal cord degenerate and that causes loss of vibration sense. Um A taxi a which is what he has. Um And what and the thing that causes subacute combined degeneration of the spinal cord. Does anyone know? Does anyone know what deficiency causes this? Okay. I'm just going to tell you because we're running out of time. It's B 12 deficiency. Okay. B 12 deficiency causes sub sub acute. Yeah. Correct. Because the sub acute combined generation of the spinal cord and where or how is B 12? Absorbed? No problem. Um uh Go go break your fast, sorry for taking so long. Okay. That's so B 12 is absorbed in the gut, but it needs to be bound to intrinsic factor produced by the stomach first. Okay. So when you do a gastrectomy, you're literally cutting off a piece of the stomach and all the intrinsic factors. Yes. And all the gastric parietal cells in the stomach producing intrinsic factor are cut away. Okay. And when intrinsic factor isn't produced by the gastric parietal cells, it can't bind to B 12. And if it can't bind to B 12, B 12 is absorbed poorly in the terminal ileum, very well done by then. I think it's a terminal, I'll um at least. Um, but yeah, so that's basically what's happened in this person. He's had a gastrectomy. He's lost his gastric parietal cells. His gastric parietal cells aren't producing intrinsic factor. Intrinsic factor isn't binding to B 12. Deficiency of B 12 causes subacute combined generation of the spinal cord. Okay. Right. We've reached the end. Here's the topics we've covered today. Um, I've got a nice little table here of all the symptoms and investigations. Each of the things we've, we've, we've talked about today. Ok. Thank you so much for joining in again. I really apologize for running over time. We'll try to run within an hour the next time. I'm sure Josh, we'll do a much better job of that. So we've got a session on urology on the 25th of April same time. 7 to 8 PM. Um Do join us, you know, we, we try to make it as relevant to exams as possible. Um, as informative as possible, please please fill in the feedback forms. Um It'll be really helpful for, for us. Um And yeah, if you have any questions, we've got my email and Josh's email here for, for you to just ask us any questions at all regarding anything. It can be about foundation starting foundation. Um S J T if you have, if you guys have s 80 next year, I don't think you do. But any, any questions, any questions Josh, you have anything to see? No. Yeah, well done. Yeah, I hope everyone enjoyed it. Yeah, we'll be doing this every Tuesday and Thursday for the next six weeks. So if you see any sessions that you like, you sound interesting, come along. Um and yeah, yeah, hopefully we'll try to keep it, keep it under time or a little bit over. But yeah, it's our first session today. So, so yeah, we'll stick around if you guys have any other questions, but I hope that was helpful for you guys. Hope you guys learn something. No worries. Thank you, Sabina. Thank you for coming. No worries by a no worries. Thanks. Thanks for coming. No problem. No problem. Do join us for next week. We've got a session on urology. More good stuff, right? All right. I think that's fine. Uh Okay. We'll stay for about a minute if anyone else has any questions, but otherwise you can always email us. Yeah. Yeah. All right. I think we can end it there. Shall we end it? Yeah. Right. Yeah, guys, again, make sure to fill in the feedback form. All right. Thank you so much. Okay. All right. See you, Josh. See you guys. Thanks for coming.