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I think we'll get started. So, hello, everyone. I'm Florence. I'm one of the chairs. Um Welcome to week five of our surgical teaching program. This week, we have been focusing on some upper gi and I'm joined by Baram this evening who is going to be taking us through some specific conditions and also some cases just before we begin, I would just like to say a massive thank you to our sponsors. So pass the MRC S more than Skin Deep um medal the MDU and also teach me surgery um matter. Thank you to them. Without them, this teaching series would not be possible. Um At the end of the talk, I will send a feedback form. It'll be amazing if you could fill it in and in doing so you'll get the recording to this talk and also access to the slides. So let's begin. I'll hand over to Baram off you go. Can you see me hear me? And can you see the slide? Yes, I can. Perfect. So, good evening everyone. My name is Bala. So I'm current your fourth year medical student at University of Leicester today. I will be presenting you two cases of colic on cholecystitis, which will make up the first half of my presentation followed on by pancreatic cancer as part of the upper gi series. So without further ado, let's get started the main objectives for this part of the presentation. First, I will cover the gallbladder anatomy, part of physiology, but mainly the bulk of the presentation will come on the clinical presentation of the conditions, investigations management and also the complications, clinical anatomy of the gallbladder. Firstly, what is the gallbladder? It is a right hypochondrium or right upper quadrant pouch like organ that stores, concentrates and controls the flow of bile. Bile is the thick green alkaline liquid that is produced by the liver, which really helps the body digest the fats. So you have the bile salts that breaks down the large fat globules which we naturally call, we digest into smaller droplets of fat. Just so the enzymes that we have the lipase that break down the fat just to make it easier. Just so we can digest it and get the nutrients. The gallbladder is surrounded by peritoneum that smooths the vasal surface and is closely related to the liver's vissel surface. And here's the image right here. There's a three key part, the fundus, which is the top as you can see right here. Can you see my laser pointer should be and the fundus typically projects into the lower surface of the liver, you then go the body, the thickest and the biggest part of the gallbladder. And then you've got the neck right here, which tapers down into the bile ducts, which I'll talk about. It's like cys duct, which I'll talk about more later on. Funny enough, there's also a little pouch right here called the Hartmann pouch, which is a common set of gallstones. And the situation it is in the gallbladder fossil beneath the right liver lobe, like I mentioned, and the arterial supply, the gallbladder is a cystic artery which is right here, which comes off the right hepatic artery. When it comes to the vein, the venous supply, it is the cystic, nice and handy. So easy to remember veins and the hepatic sinusoids which primarily give some to the fungus in the body. Whereas the veins drains the neck. When it comes to the sympathetic innervation, it is applied by the Celac plexus. There are nice bundles of nerves which are right behind the pancreas and close to the aorta. And when it comes to the power, sympathetic innervation, it is supplied by the vagus nerve that comes into our first question. Nice and easy question. What number cranial nerve is the vagus. If you guys pop your answers in the chat, that would be really helpful and I will read them out. So one number Creal nerve is the vagus nerve. I'll give you a couple more seconds. And then number 10, we have an answer. Number 10. Perfect. Thank you for the answer. Yes. Number 10. Why it is important for the power sympathetic because the go body, of course, it releases the bile. So when we do need to have that rest and digest the color, the, the go body can relax the sing of body, which I mentioned later on just so we can get the flow bile into the duodene. Thank you for that answer. Now, let's talk about the bili re tree. So B is a collection of the gi docs that allows the flow of bile produced from the liver all the way to the duodenum. We can go and digest the plants. You first got the hepatic ducts on this side, right? And the left which then join together to nice name common hepatic duct and then it comes to the gallbladder. The main structure is the cystic duct. So we think of cystic, always think about the gallbladder which go in and out of the go bile and then the common bile duct and the pancreatic duct right here forms the common hepato pancreatic duct. Quite a long name, also known as the um ovata, which then empties into the second part of the duodenum. Then it can do what his normal function is. And then you have this nice structure here called the sin of which is a smooth muscle valve that controls the flow of bile and it prevents the reflux of duodenal contents because the last thing you want is a content going back up into these places where it's not meant to be. And CCK cholecystokinin is a hormone produced by the sorry small intestine, which controls how relaxed or cancer sphincter order is when it's acting, relax the sphincter or the muscular valve allows the flow ball into the small intestine. And this is just a close image of the oncolo vata. Like I mentioned small opening here into the second part of the duodenum release of secretions into the papilla, which should then these into the duodenum. And then it's actually the key anatomical structure because it marks the transition from the fot to the midgut, the vata and the second part of the duodenum. And then you also have the minor duodenum pillar which is near the structures which is mainly the opening for the accessory pancreatic duct. Of course, the main talk today are gallstones and be pathology. So what are gallstones? They're typically an abnormal deposit of solid material like the bar also calcium or cholesterol formed within the bi tree. Interesting of the heaviest recorded was actually 6 kg and even just a bit above that. So imagine a that big of a stone inside your gallbladder, even in your body must not be quite pleasant. Typically, there's three main times there's a cholesterol gallstone. How together if you have excess cholesterol production pigment. So from the bowel pigment, you have black and you also got brown black, you're normally with chronic hemolysis. If you break down a lot of the hemoglobin red blood cells. For example, in sickle cell disease or thalassemia, you also got brown pigment stone, which is interesting enough associated with parasitic infections like worms. And then you have the mix of bare burs, bare cholesterol, bare pigment gallstones are actually asymptomatic in 80% of patients and is normally found on an incidental scan if you need an ultrasound scan for something else or for another reason and is picked up, however, it can lead to some problems which I will talk about now. So let's imagine if you're a medical student or a healthcare professional and you take a history from a 35 year old female JC who is in really bad pain for the last five hours. She didn't know what happened after eating some margarita pizza from a local pizza place. She had waves of eight out of 10, right of co pain that can last for 20 minutes at a time, which obviously may not seem as bad because 20 minutes, ok, not that bad. But if you're a patient with 20 minutes pain, it can I imagine be quite excruciating, especially how it weighs an eight out of 10 she feels and looks a bit queasy and vomited twice in the past three hours on further questioning, she takes atorvastatin for high cholesterol and she's been gaining quite a lot of weight in the past year just due to some unhealthy eating habits. On examination. She is alert, writhing around in the bed and on palpation, some bright upper cod and tenderness with a Murphy sign negative. I will talk more about Murphy sign in my form signs observations apyrexial no temperature, heart rate, 8915 respiratory rate and 1 25 85 BP. So nothing too concerning in the observations and examination. So question in the chat. What do you think could be going on? Given this history from JC again, if you just pop your answers in the chat, that would be amazing. And I'll read them out. We've got binary colic. Perfect. Amazing answer. So yes, bi colic is what she most likely has. What is colic? Bi colic is a sudden painful spasm of the gallbladder wall caused by gallstone. So the gallstone will impact in the gallbladder or cystic duct and then when it's impacted and when it contracts, it will lead to the inflammation and then it cause the pain, risk factors. You can name it as the FS five to even obesity, female, 40 family history of go on the go on pathology and also estrogen exposure. If you are, for example, if you have a pregnancy and also if you take any contraceptives, how does it present? Similar to JC, sudden dull colicky, so quite wavy, right, upper quadrant pain. But just remember, it can also be quite similar in nature and the surrounding areas to the epigastrium or also to the bark. Typical patient can be, they've had some pizza or some fatty foods late at night and then it woke up with this pain. Why is fatty foods a trigger? Because the hormone, which I mentioned prior colicy kind is actually stimulated by fats and proteins. So if you had, let's say a fatty food, you can, what does it do? Relax the swing of cause a ball to be bound to go out. But however, there's a gallstone, they call it gall to glod into the cystic D. So that's why the trigger is fatty foods, noise and vomiting is another same time quite sweating and it can have some palpitations. And the main point of this is, of course, you can get this history, you can have all these presentations, but the main part of healthcare professionals is to dissect and find out what's the most important part just for your diagnostic reasoning. So, in this case, she's 42 she's female as a risk factor. Margarita pizza has some cheese, quite a bit of fat in that sometimes. And the waves of pain, colicky cause patients don't always say I colic. They normally tell waves queasy, she vomited and she's gained a lot of weight. Another pathology similar to B choleric except a little bit more advanced is cholecystitis. You can break the name CEG. You were thinking more like pathology, an itis inflammation. What is it? Acute gallbladder inflammation? This factor, same as Billy Colic presentation how it is a percent. So, of course, it is more repeated inflammation. It can be some from gallbladder having constant impaction and repeated inflammation on billary col. So it has constant right upper quadrant or epigastric pain tenderness more than six hours. And it's sharp, localized and exacerbated by movement, the sharp and localized it due to the fact that if it's constant pain for more than six hours, the parietal peritoneum, which is I think more somatic and visceral. So somatic innervation will lead to the sharp local in nature of the pain, shoulder tip pain. The reason for that is it can cause some phrenic nerve innervation. So, phrenic nerve C 345 also supplies some innervation to the shoulder. So you have some preferred pain, fever as the itis inflammation, vomiting, the pain, tachycardia, ving, guarding and peter like I mentioned before. And Murphy is positive Murphy sign that common sound that we seen in our ay to perform or even when you learn it, how you perform it is when you ask the patient to exhale, you look at the midclavicular line, located the right costal margin, place your hand in the right upper quadrant in that area, ask them to exhale, push your hand in, ask them to take a deep breath in and out and either take a deep breath in the lungs, expand, push your gallbladder down, it hits your hand, the gallbladder and it causes the sudden irritation leading to winds and gasp for breath. So it is quite painful. However, it can sometimes be negative in 50% of patients cholecystitis. And sometimes it can be confuted by colic because of tenderness. That's why performing it correctly is important, but it's not always presenting cholecystitis. So you have this patient and let's talk about bi colic and also cholecystitis in the chart. Can you please just list some investigation that you have to order for this patient? Please pop your question in your chart. Our vs can read different LFT S. We've had anybody else it good that CRP we've had. Yeah, ultrasound. Nice. That's good. Amazing suggestions. So I've made this table right here to just summarize the key investigations. When you do, for example, present one investigations like to order it is best to have the bedside bloods imaging. So of course, you are thinking is colic or even cholecystitis for another patient, but you still can root and root out other pathologies. So you actually do ecg sometimes if they have you suspecting it has some sort of acute conny syndrome or aortic dissection picture just because if they may describe a chest pain rather than a typical whatever quadrant urinalysis, if they're having uti or pyonephritis. And always, if there's a female patient who presents abdominal pain, you can never forget pregnancy test just to not rule out blood test. Like you guys mentioned F CCR P LFT S, amylase, amylase is still important because pancreatitis can still present similar to holti or any abdominal pain. You can never forget pancreatitis in blood test. The L PS is typically normal but it can sometimes show raised ap. However, cholecystitis, inflammatory in nature, raised white cell count cr PA RP and sometimes bilirubin can increase as well as gaming t ultrasound. One of the main investigations, what can you see, you can see the pre the gallstones, it can be impacted and I'll show you a picture later on. It can cause a thickened gallbladder, which is more indicative of inflammation, bile duct dilation, which means there's a stone impacted in the distal bile duct and edema CT scan for cholecystitis. You, you can perform it. It's not always perform but you some perform it if you're not too sure about the picture of your doubting diagnostic ability sometimes and you just want to confirm it is or also the cholecystitis has perforated. So, a patient who has some vol guarding high fevers and what can it show can show the gallstones the thickening the perforations and also some inflammatory changes. M RCP. You would simply an MRI scan you could take of the pry which shows some amazing images. You would do it if ultrasound scan doesn't really pick up the gallstones, but there is also dilation and LFT S abnormalities. So, just to confirm it. So, yeah, amazing. So this ultrasound scan on the left. So a right here and b what do you think it could be. So a what do you think this is pointing to or do you give it a hint? What organ do you think is pointing to a on the left picture where two answers in the chat, please. A special shout out to Alice and cat who have been holding us up here. Alice says the wall of gall of the gallbladder. Perfect gallbladder wall. Amazing. And b what do you think this structure could be? Little hint the whole presentations practically on this. And cats says a stone. Amazing cat gallstones. I would like to bring attention to sludge. Sludge is the material that's not really pre uh is precipitated by the gallbladder, but it doesn't really form a gallstone. It like a prerequisite sometimes. And on this case, for the sake of time, I'll just describe the images. So A is talking about stones in the distal common bile duct. You got B which is the stones in the so bile duct and then you got C the pancreatic duct and D the duodenum. So I think so maybe just talk about it and management. I will just typically talk about this. So Bill col you would to of course, then pain, you get some analgesia, you will give them antiemetics if they're vomiting and lifestyle change is important cause you don't want this to repeat again and it can be reducing the weight, having less fatty food triggers and just some overall better changes and you would like to perform elect sorry, elective laparoscopic cholecystectomy of the moon of the gallbladder. And for cholecystitis, similar analgesia is quite painful antiemetics or IV antibiotics. In case of an infection, you like to do lifestyle changes. And in this case, an emergency lab that's called a cholecystectomy because if it's infection and they're lasting, you want to develop any secondary sepsis and you actually do typically within 72 hours. And that's the best time for you to optimize a patient outcomes. As if you waited for it longer, it can just make it harder for you to perform it and lead to more complications. But never forget us. Healthcare professionals always safety net safety net safety net, especially for example, if they're waiting for cholecystectomy because the last thing that you want is then presenting into cholecyst or even a pancreatitis picture. So you always warn them of the science and what to do to do, develop it. However, we're not done yet on your next attachment. At A&E six week later, you see JC again and then you clock off, she now complains of a two day history of vague abdominal pain, constant vomiting of yellow green vomit and she's not been going taller that much. It's been slowing down when you examine her. You note abdominal distension. I know it's quite vague, but I'd appreciate what do you think could be going on and a possible explanation of the underlying cause. So this picture. What condition do you think this typically presents just a quick answer in the chat that II in the chat, please think about constipation, green vomiting, abdominal distension, abdominal pain. Of course, this is more, let's say a bit lower gi but it still can be implicated in course. And pathology we've had problem with bile production, maybe. Ok. Interesting. Um, small bowel obstruction. Perfect. Yeah, that's the right answer. Small bowel obstruction. I'll tell you why on the next slide, but good abdominal distension, green, the bi vomiting, constipation and abdominal pain. And I explain to you why you can get bowel obstruction with gallstones. So, complications, there are four main ones. So, Merisi syndrome sounded complicated but is when a stone is located in a little Poch which I mentioned earlier on or in the cystic duct itself. What's interesting is if the stone is quite big enough, it can compress on the adjacent common hepatic duct which can then lead to obstructed jaundice, yellowing of the skin or sclera. And it's with us even without even go on being present in the hepatic duct. It just on the compressive action. I was before and investigation. M RCP, highly treated laparoscopic cholecystectomy. Another complication, chronic cholecystitis, persistent gallbladder, wall inflammation due to recurrent or untreated cholecystitis which can lead to gallbladder, carcinoma because ch chronic inflammation can be prerequisite to pathology of carcinoma. Even the pathogenesis. How does it present? Ongoing? Right? Ard pain, nausea, vomiting, you can check it out on a CT scan and you have to perform an elective cholecystectomy, which, which is why it important to always safety net on how it can present as cholecystitis and what the warning signs should be to prevent from being in this condition. Gallbladder, empyema sary, like for example, from a pneumonia except this time, it's a gallbladder from the pus and pus nasty material you don't want in the body. It can present cement, consti with swinging fevers and sepsis. You have do ultrasound scan. CT definitely do IV antibiotics and sepsis. Six. Potentially, if you have any sepsis picture, you will have to do an emergency, laparoscopic cholecystectomy, maybe. So also you can do interrupted drainage. It tends to go better just to relieve that pressure and a percutaneous cholecystectomy, which is similar to draining goal of I this is linked to the previous line. So the gallbladder can form a fistula which is a connection between two organs to the small intestine. And as a connection, the goal are kind of slide down and pass diverted into duodenum and it can then impact other term io leading to the small bowel obstruction. So if someone says, what are the causes of small bowel obstruction, hopefully, this is one thing you can remember. Gallstones can always cause it. This is just uh some slide just for your own landing. Do compare colic cholestat colic temporal infraction on the neck, gallbladder, cholestasis, acute inflammation, colic bic oy episodes of the pain, whereas cholestat is constant pain systemically. Well, patient colic B colic. However, cholecystitis is systemically unwell with a fever tachycardia, you will then get a ma you sign positive. Whereas it's negative in colic, you would like to also do a blood test and you see a raised white cell count cr PA LP. Whereas normally it's normal in Bilic treatment. I antibiotics, emergency laparoscopic cholecystectomy when it comes to causing scientist. Whereas a biol elective analgesia antiemetics and H one, we can just get rid of the gallbladder. So thank you for listening for this presentation. We've covered the anatomy. We covered a pathophysiology called We did the clinical presentation with patient JC. We performed some investigations on what it looks for, even covered a management plan and also covered complications. Here's the links on some of the information I got on the pictures and if there's any questions pop in the chart, if not, I can just put on the next presentation. So yeah, just pop any questions that you may have in the chat and we'll do the best to answer them. Thank you so much. That was so helpful going through that presentation in so much detail. No, thank you and thank you for the child for interrupting. Yes. Thank you guys making my life easier instead of me having to have a guess. And also generally when you do interrent presentations, you can treat it as an essay. Q and also with the pressure of, for example, everyone on the chart, if you do get it wrong, if you do get it right, it will then stick in your head more. And if you do get the exact same question again, you will then think about the time when you did answer it. So it is beneficial for everyone, you know, for your own learning. If there's no questions, I will just move on over to my next. No questions. You've just got a thank you. No problem. Thank you though. Much, appreciate it. OK. All righty pancreatic cancer, similar in the bellies, objectives, pancreas, anatomy, epidemiology of the pancreatic cancers, classifications, the main types, risk factors, presentation and DD or differential diagnoses investigations. And also plan with the main focus being on the lot of bos let's just briefly talk about pancreas anatomy. It is a retroperitoneal glandular organ with exocrine and endocrine functions of the epigastrium and left hypochondrium. So quite an important structure situated on a trans Palo plane which is at the level L1. And here's a nice image right here, tucked in quite nicely with the surrounding structures and it's, I think it's posterior to your stomach and that's important five key main points you have that. Ok. So let me get my laser pointer out. Yup, you got the uncinate process, which is key part. It also where the super art and vein intestine. You also got the head of the pancreas the neck, the body and the tail. Quite simple functions. Exocrine. So we do what exocrine think about producing enzymes. It produces the enzymes to break down the fat carbohydrates and the proteins just so that we can absorb the nutrients and we can get the benefits from it. Endocrine. The alpha and the beta cells produce glucagon and insulin respectively. Of course, I can do a whole electron glucon and insulin. But of course, we all know that it is involved in blood sugar control how insulin can reduce glucon increase blood sugar when needed arterial supply. It's from the pancreatic branches of the splenic artery. Also, the head specifically is from the superior and inferior pancreatic du and arteries, bit of a mouthful and that's typically from the respectively and then the venous apply from the splenic veins for what it drains. And the head has to be different. The superior branches of the hepatic portal vein. Of course, a lot cover here in the anatomy. However, the main focus of the presentation is on pancreatic cancer. So, pancreatic cancer, the fourth most common cause of cancer related deaths. Majority of the cases are in 60 to 8080 years old. And interesting enough, the five year surv I think sorry, the 10 year survival or the five year survival is only around 10%. And the reason for that is it typically does present late, I will tell you why that happens in my next lines. The most common type is a ductal ade adenocarcinoma. When thinking ductal adeno, you think about the exocrine, so more the lining of the cells of the ducts, it can have further exocrine, more niche tumors like the pancreatic cystic carcinoma. But like I mentioned, endocrine functions. So you also can have some endocrine related tumors from the eyelid of langa. Hands. Main important 0.60 to 70% of pancreatic cancers occur in their head of the pancreas. And why that's important is because as we've seen the picture before the head of the pancreas is more, let's say in close proximity to the common bile duct. So if there's a growth on the head of the pancreas, it can compress onto the common bile duct, lean to the symptoms, which I'll talk about later and why that's important because if you do get symptoms, you would present earlier on. However, in the body and the tail of the pancreas, it's quite further away from the head. You can get cancer, it can grow, grow, grow, but it typically won't present it present quite late because it won't press on a common bow to produce the symptoms. And a fortune at that stage is quite late to do any curative treatment. So that's the main point for why head of the cancer and how, why anatomy is still important when it comes to anatomy and your diagnostic reasoning again, let's do another patient case. You are a medical student or healthcare professional who decided to go to surgical assessment unit. Just so for from extra surgical history, taking practice in preparation for your upcoming exams, you think you can hopefully squeeze in a possible appendicitis case lower, right quadrant pain typical before you have your lunch. As you forgot to have your breakfast, you snooze to a lot, but it's not appendicitis case. You see, it's something quite interesting. MQ. You greet a 75 year old gentleman empty, accompanied by his daily wife with a history of diabetes, hypertension and gout who presents with a change in his parents and his bowel habits. He complains of a four week history of vague abdominal pain and recently noticed that his stools are quite greasy and takes him a couple more times to flush. He chuckles me, tell you this, that he thinks it is quite embolis. His wife then says that for the past two months, he looks a bit more yellow. He this his color has not been the same. They thought probably just because he eating a lot of fruits and vegetables. Like sometimes when you have a lot of carrots, it can cause the palms of your, like your palms to go orange due to the beer counting and they have to constantly spend more money on buying new jeans and they keep on getting bigger and bigger and bigger. Uh No. However, there is no history of infected contacts or significant travel history just a bit background, sister and mother died of breast cancer at 35 and 40 years old, respectively. Unfortunately, he takes Metformin, amLODIPine and Allopurinol. No known drug allergies. He's a retired builder drinks 20 units a week, but he did cut it down from 35 units a week. So still some improvement but still quite large consumption of alcohol. And he does have a 20 pack year smoking history examination. He's jaundiced CT protected tar staining his fingernails, which is why it's always important to always examine the nails. You could find so much pathology, not even just with gastro, just even when it comes to dermatology. Also tenderness in his left upper quadrant and also an epigastric mass is felt. So risk factors presentation is on pancreatic cancer and it, I'll tell you why it's so important to diagnose it because of how it can progress quickly. But the challenge is, is it's easier saying now than don't because we can see how vague the presentation is. So, when it comes to pancreatic cancer, there are many risk factors, advancing age, male, gender smoking, obesity, chronic pancreatitis, similar to cholecystitis, you have a lot of inflammation, you're more likely to have the DNA damage and induce carcinogenesis, diabetes, mellitis, which is quite interesting genetic conditions like H and PC, which is more implicated in colorectal cancers. BRCA mutations and excess alcohol consumption. BRCA. Of course, with the BRCA mutation is important because people is always anonymous with breast cancer because it is the most common cancer implicated in it. However, it can cause cancer in males, lesser chance pancre, pancreatic and prostate. So always look into the genetic history as well. Signs and symptoms. Like I mentioned previously, it does present late due to the vague and nonspecific nature of symptoms. See early painless obstructive jaundice, jaundice because of compression, the compound duct weight loss that can be from the inflammation of the cancer leads to cachexia also from the exocrine insufficiency. So it's not releasing the enzyme due to defective nature of the pancreas, they can't absorb the nutrients and they, they can't really gain weight, nonspecific abdominal pain, which can be from invasion of the celiac plexus, late onset diabetes, mellitis may be the presenting feature for pancreatic cancer, which is quite interesting. So if you do have a patient, 55 years old HBA1C, quite new and abrupt, always on the back of your mind. Ok. Let me screen for other symptoms of pancreatic cancer may just be a false alarm, but you'd rather be safe than sorry because like with this fact, eight times greater risk of developing pin carcinoma in the following three years. So it's always important to screen ste arturia, oily, foul smelling stools that are difficult to flush away. Of course, when you're asking this question to patients, they may like, ok, why is he quite interested? Isn't it a bit weird? But you can explain why it's important and it's always important to figure this out as a key symptom examination protected, quite wasted malnourished exocrine insufficiency jaundice and an epigastric mouse with maybe not enlarged gallbladder as per qua Fer lo this typically says that if you do have obstructive jaundice and an enlarged gallbladder, the main pathology that you like to think about is gallbladder, carcinoma, or BV, duct carcinoma and pancreatic cancer. So in depth examination is always important when a person presents with these symptoms. Why I revisited the case is because it shows that you can bring the textbook together with a real life patient. Because normally, for example, you can say all the main symptoms and signs of any condition of bowel obstruction can or even let's say an eczema, but it is a patient in front of you with size, not always textbook. You got, you put your thinking cap on and think about, OK. It may be this, it may not be that and then utilizing what you learned in a textbook, an actual real life patient, then you can tell your questions. So let's talk about it. With this case. 75 years old, you've got advancing age type two diabetes, ok. Vague abdominal pain, greasy stools, ok? You getting more of the picture that is more, let's say bilary in nature or pancreatic 3 to 4 times too flush, yellowing of the skin, buying new jeans. Patients will always say yes, I've lost weight. Yes, he looks protected. You have to figure it out. So buying new jeans can be keep getting smaller or thinner. So it's something like that. You got like pinpoint two things together. Sister mother died of breast cancer. You probably thought, OK, that's probably available in this case. But then you remember breast cancer at quite a young age could be a BRCA mutation. There. He drinks 20 units of alcohol and he smokes quite a lot. So he does have a lot of risk factors for pancreatic cancer and also with examination as well, which confirms your findings. So ques so answers in the chat with this patient or pancreatic cancer. What investigations would you consider? Ok. So what investigations would we like here? Think about bedside, think about bloods imaging. We've got an M RCP. OK. Amazing. Let's think about, for example, to stage a cancer. What's the traditional investigation you like to do for most cancers? Just to see the disease of spread? We've got L FTC RP and maybe an O DG. Ok. We've also had a biopsy. Possibly. Hm. Nice. I'll give you a nice summary of the investigations. So blood test always do blood test and they can have some anemia if they have any bleeding, low platelets, if they have any D IC. So D IC disseminated intravasal coagulation. I want in detail is when you have depletion, coagulation factors. So you can have some thrombosis but also some hemorrhage. Main thing is malignancies can cause this raised LFT I can measure the chat raised bilirubin A LP gamma GT. The main one, it is a tumor marker. It is AC A 199. OK. When it comes to tumor markers, it's not always diagnostic because it can be raised in obstructive jaundice. However, the main function of it is just to track the prognosis of the patient. Or even for example, let me administer some treatment. If it goes down, that probably means it is working again. When you have something that's hepatic pancreatic ability. Ultrasound scan is nice and easy to do. You can then potentially see your pancreatic mass that doesn't even liver metastases. The main investigation I was alluding to is a CT scan or CT chest abnormal pelvis with IV contrast also known as a pancreatic protocol, which is why you can see a pancreatic mass. You can see the extent of the local distant or spread. Also, if you're not too sure what it could be or you need some more further investigations. You can do a nice pet scan, it can see the pancreat mass and it can be useful for the extent of spread or the staging and Mr ICP, because that can do a beautiful image and it can assess any duct for a month. So thank you for putting your answers in the chart two. Be great. So I know we're more focused on the hospital side, but you can never forget in a primary care setting. There's also guidelines in place for pancreatic cancer. And I thought this would be useful, especially with this pyic. So any patient who's over and equal to 40 years and has jaundice straight away, you do a two week degree while just to be urgently seen because you don't wanna miss anything out. However, if there's 60 years and above and they have some weight loss, plus these symptoms and nausea, the vomiting, the new onset diabetes, which is why we know why diarrhea constipation, back pain, you will have to do urgent ultrasound act scan just to see if there is anything s all. So when it comes to differentials, I'll just talk about it here. The main differentials when you call it differentials, actually, you will have to think about it. You can just keep it simple. So of course, what can you can break it down? What can cause jaundice, what can cause this weight loss, what can cause all these symptoms and then group it down rather than just memorizing differentials just for the sake of it because in medicine, you can just work it out just from the basics of it. So, pancreatitis chronic, it does present similarly. However, there, the distinguishing features is there can be some histological differences on act scan, they can see some pancreatic atrophy. However, it is quite hard to distinguish both of them, which is why you always do the CT scan of that investigation to just confirm gallstone disease. But as you know, it presents with a right of a quadrant colic pain typically younger and you will see the gallstone findings on investigations rather than any pancreatic mass cholangiocarcinoma. Another malignancy, you'd have a history of primary sclerosing cholangitis, which is the inflammation that you can paly always see or you're always just so sick, sorry with ulcerative colitis or even a history of liver cirrhosis because of the underlying inflammation. However, when you do investigate this, you have an absence of pancreatic mass, but you do show a thickening in the bow because of course, it is a malignancy of there peptic ulcer disease because it could be the vague abdominal pain. But when you do take a family history, they would have an NSAID used, for example, take ibuprofen with no lansoprazole for an arthritis. They may have some h pylori infection and they have a bad ignoring pain in the upper abdomen. And as we learned in the textbook, it can be relieved by eating something with a duodenal, like we said, better worth eating. And also if it can progress, it can lead to hematemesis. GERD reflux quite common heartburn symptoms, the acid taste in the mouth, the feeling that you just have some chest pain. However, it is better with Gaviscon or PPI gastric cancer. It will lead to the dyspepsia at the left of a quadrant pain, early satiety hematemesis, melena and V node is when you get a raised lymph node in this left supra clavicular fossa right here. So many option for pancreatic cancer before I begin, can you guys just list what kind of main option do you think at the moment they are for pancreatic cancer? You can be broad and not look for any specific. Just for example, one of the main pillars of treatment, palliative care, um Whipples. Amazing. So yeah, two amazing suggestions and I do like palliative treatment as a good answer because sometimes people always focused on surgery or chemotherapy like I mentioned. But pillow K can sometimes always be the only option due to five. It does present late. So when it comes to management, you always break it down to, for example, the degree on the staging and the grading. So if it is resectable, you will have to do ac section which is a ripple procedure. But there's also another procedure which I'll talk about in the next slide. And you may also do some adjuvant chemotherapy, adjuvant chemotherapy. So adjuvant simply means you do perform the chemotherapy after the surgery just to prevent any or minimize any disease recurrence and just optimize the outcome. If it's borderline resectable, you can do surgical resection, but just to optimize that we can do some chemotherapy and also put in a belly stent to just so it measure the bowel ranges nicely if it unfortunately is locally advanced, there's all these options, which of course is patient focused on whether the patient wants it or not. You can put a stent in endoscopically, you can do some palliative surgery, chemo, chemo, radiotherapy and stereotactic body radiotherapy. Don't worry too much about to about it right now. Later on, if you, let's say you're early on your medical school career. If you're like year one, year two and you're watching this, you learn more about this, you know, oncology, placement, but stereotactic body radio therapy, it is a type of radiotherapy that can help with some cancers. Unlike the good answer in the chat, if it is metastatic or it does present correlate, there are some palliative care options. We've just had a quick question. I'll just ask it now. Um We've had a question. What does resectable mean? Good question. So resectable is when you're able to take the chunk or the cancer out. So let's say that the cancer is probably impinging on too many structures or it, if you, if you take it out, it can cause more harm to the patient, then you won't be able to take it out because you've cause more harm. However, if it's in one place where it's quite localized, you can take it out quite easily. It's quite early on in presentation then that's when you can resect it, resect. Take it out. Does that answer your question? Yep. It does amazing. Thank you so much. Oh Thank you. So it comes through these words, me, Sect boom. Take it out types of surgery, the main 11 of the most famous surgeries performed when it comes to gi is whipple procedure. Or if you want to learn the name name pancreaticoduodenectomy with regional lymphadenectomy, which means removal of the lymph nodes. So when masectomy in its removal as well, lymph lymph nodes. So when it comes to medicine, once you get the lingo of things, you can work out what the word means by just breaking down. So, pancreatic pancreatic duo duodenal omy removal, removing the pancreas and the duodenal lymph lymph nodes, ectomy, removal, removal of the lymph nodes. But in this procedure, there is a bit more complicated. You do perform this in pancreatic head cancers. And it also removes the pancreatic head. Of course, the antrum of the stomach, which is the top part duodenum, one and two be dune is split in many parts, the CBD gallbladder and the lymph nodes. The reason why you take all these out is because it does share a common blood supply. That's the reason why. And this is a nice image of what starts to actually take out. You've got the gallbladder, you got the pancreas, the duodenum. So it is quite a big and long surgery. And then this one is when you have a cancer in the pancreatic body and tail is the distal pancreatectomy and splenectomy with regional lymphadenectomy. So cause a lot of ectomy removal, removal, removal. But in this case, you remove the body, remove the tail, you also remove the spleen and also the lymph nodes and when it comes to Pelvi treatment, because that's still a major option when it comes to pancreatic cancer treatment. The main options are endoscopic stent insertion, you put a stent in just to relieve any bile after the obstruction, palliative gastroenterostomy. All these big names, I'll break it down right here. So, pancreat cancer because it's posterior meaning behind the stomach. If the cancer goes big enough, it can cause some obstruction of outflow from the stomach content. So nothing leaving in the stomach. So how can we relieve that? We perform a connection between the gastro stomach and Jejunum, which is the Jejunum, which is the part of the small intestine. You poor connection between the two and then the stomach can directly drain from them. Percutaneous, meaning through the skin biliary drainage because the cancer can impinge on the Bellary duct and nothing can leave out if it's that bad. You just relieve out some of the pressure from a drainage of the biliary part through the skin analgesia because they're probably in pain. So you like to give him some pain relief due to the fact that they have some exocrine or glandular insufficiency because there's a cancer in the pancreas. It can't really get that much enzymes or produce that much enzymes. Let's top it up. Let's give them some supplementation known as Creon, which then helps them break down the f and then they can then gain weight, gemcitabine and immunotherapy. These are just the more chemotherapy or immunotherapy that can use pre or post resection or even that could be the only form of treatment depending on the patient. And olaparib more of a new drug in picture is typically more the systemic treatment where is more fine tuned because right now the future is all these immunotherapy, all these targeted cancer therapies and all polyps seems to be one of them. And and hopefully there's all new drugs to come which can help optimize the patient outcomes. So, thank you guys for listening. Today. We've covered pancreas anatomy in the second half of a session, we covered epidemiology, we covered classifications of pancreatic cancer risk factors presentation, how they could present and why it would always be straightforward. And you always got to think about what could this be and how does it present similar to other conditions with the differentials? What investigations you would like to order and finally the management plan for someone with pancreatic cancer. And I'm sure, you know, it is quite complicated. There's all these criteria that needs to be met. Every patient is different. They have their own patient wishes, they have their own comorbidities. But at least we know there's still quite some option out there to not only treat the cancer, but he also help the patient quality of life because that is fundamental in a patient. So I've been balancing. So Thank you guys for listening. Here are some references and the presentation is now finished. Do you guys have any questions? Thank you so much. That was incredibly helpful and I really enjoy going through the cases as well. And thank you so much to our audience for getting involved as well and putting answers in the chat. Yeah. Thank you. 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So follow us a med and you'll get notified when those sessions are going to be so amazing. Thank you so much to everyone. No problem. Have a nice evening. Bye bye.