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Yeah, just waiting for it to be like, yeah. Yeah. Sure, perfect. So, hey, everybody, thank you so much for joining us today. Um, we'd like to have our eight week in our teaching series and today this is gonna be on the topic of lower gi surgery. I would like to have doctor today. He's gonna be leading the session. I'm really looking forward to it and hope you guys are able to take a lot from me too and without further ado I hand over to doctor. Yeah. Yeah. Hi, everyone. Uh, my name is Mara. I'm working as a general surgery with JF in Blackburn at the moment. I've cleared my CS and I'm hoping to apply for general surgery in the near future and should we wait for more people to join or should we just crack on? Um, I'm happy to crack on. Usually we do give a couple of minutes just in case. But, um, yeah. All right then thank you. All right. Let me just share my presentation and then we can crack on if you guys have any questions, just put them in the chart and we can talk about it at the end of the session. All right. All right. Can everyone see my screen? Yeah. Anyone just say yes. Yeah, you can see. Thanks. Good. All right. So, so, well, before we talk about lower gi um I've had a good thought about what should we talk today in this session? And then, well, the most I can promise you this the most common bleed you're gonna get. If you start working in general surgery, anywhere in the entire in HS is acute abdomen. So if you talk about what acute abdomen is, 81 who present with a nontraumatic abdominal pain with symptoms such as fever, bumping or any other constitutional symptoms is actually acute abdomen and know one of the most common causes of acute abdomen we see in the EDS is appendicitis. So today we'll talk in detail about appendicitis and we'll talk briefly about other acute abdomen presentations as well. So to define appendicitis, appendicitis is the inflammation or infection of the appendix. Very surprisingly, it is actually one of the most common acute surgical conditions you're gonna see as a gen search doctor gonna start working in the department. So which age groups normally present with appendicitis? It's usually among 10 to 30 with the prevalence being in the teenagers, usually between 13 to 19, but occasionally they can actually be a bimodal presentation where you see few patients who present with appendicitis even after 40 to 50 years of age. And quite surprisingly, around 50,000 appendicectomy are performed per year in the UK. So before we talk about appendicitis in detail, let's talk about appendix per se. So appendix is a blind tube which has a lumen that's attached to the cecum. So the appendix has two parts, the base and the tip. So, well, if you look at this figure, this is the base. So the base of the appendix is constant, which is attached to the cecum. But the tip of the appendix can be found in several different positions such as retrocecal, which is arguably the most common presentation or the position of the appendix. You can have other lesions like pelvic, sub cecal, preileal or right PICO as well. So usually the appendix is about 5 to 10 centimeters. If you take a look at this figure, you can actually see the tia coli. So tia coli longitudinal smooth muscle folds that run along the large colon. So the base of the appendix is where the temia converge. So that is how you identify appendix quite easily intraoperatively as well. So let's talk about the vascular supply or the blood supply of of appendix. Appendix is derived from the midgut. So usually when you talk about gi you need to know about your fore gut, your mid gut and your hind gut. So your fore gut is from your esophagus to the mid, your midgut is from the mid theorum to the mid transverse colon and your hind gut is from the mid transverse colon to your rectum. And your appendix is a part of the midgut and its blood supply is mainly the appendicular artery, which is a branch of the colic artery, which in turn is a branch of the super meric artery. And the venous drainage is via the corresponding appendicular veins. And let's talk about the nerve supply. So you have both the sympathetic and the parasympathetic nerves innervating the appendix. This is mainly from the superior meric flexus by the ileocecal branches. And these nerves run parallel and they accompany the I ilio colic artery to reach the appendix. Now, when, when you see a patient who presents with appendicitis, the most common sy symptom or the clinical feature is that the pain usually starts centrally and it then moves to the to the right side to the right left fossa. Now, the reason behind this is initially, the pain is because of the sympathetic nerve endings which arise from the T 10. And that is the reason the pain is initially central and this is called as viser pain. Later when the inflammation is more focused in the right left foza, your parietal peritoneum gets stretched and that is the reason in the later half, the pain is in the right side of the abdomen. Now, if you talk about the pathogenesis of appendicitis, if you remember, I told you appendicitis is a blind tube which has only one opening and that is into the s. Now, when the appendix lumen gets obstructed. And this can be because of multiple causes such as fecolith or foot materials or lymphoid hyperplasia, or less commonly because of appendicular malignancies such as cecal adenocarcinoma or neuroendocrine tumors of the appendix itself. So when the appendix, the lumen of the appendix gets obstructed, this results in the bacteria multiplying in the wall of the appendix and the lumen because of bacterial translocation And this results in acute appendicitis. So if you take a look at this picture, this is where initially the wall of the appendix gets turb because of bacterial inflammation. And the rate of accel of inflammation increases once there is Luminal obstruction. Now gradually, once the bacteria start multiplying, this causes localized inflammation and this results in reduced venous flow. And this in turn increases the intraluminal pressure of the appendix that gradually results in ischemia of the wall of the appendix per se. And if this is left untreated, the ischemia can gradually cause necrosis of the appendix, which in turn causes the appendix to perforate. Now, when the appendix perforates, this can result in two of these. One is where the appendix perforates and causes peritonitis, which results in pus in the four quadrants of your abdomen. And the second is when your appendix perforates, but you have a really good defense mechanism which is the omentum which goes and attaches on the appendix and surrounding this, the bowel loops of the small bowel gets attached to this as well. So the entire inflammation gets contained and this is called as an appendicular mass. So this is the appendicular mass where uh we spoke about how tomentum and the coils of the bowel get attached on the perforation which causes an appendicular mass. And this is where the appendicular perforation results in outpouring of pus inside the abdomen, which contaminates the entire abdominal cavity and causes peritonitis. Now, if you talk about the symptoms, so the earliest symptom in appendicitis is actually abdominal pain. And like we spoke about this, abdominal pain starts in the central abdomen. And this is because initially this is the visual pain. Later when the infection or the inflammation gradually worsens. The pain is more localized or vocalized in the right leg fossa. And this is because of the stretch of the parietal peritoneum because of the inflamed appendix, gradually, the pain becomes diffused, which spreads around the entire abdomen. And this can actually indicate that this might be appendicitis which has perforated and has caused tanit, if you talk about other symptoms of appendicitis, other than the pain, one thing usually does not precede pain, but it occurs after the central abdominal pain. You can also have anorexia, nausea or diarrhea itself. So this is a really good picture which tells us about the clinical symptoms of appendicitis. Like we spoke about, the peak incidence is actually between 10 to 12 years, let's say 10 to 30 years, but it's more common in the adolescent. And the pain begins as a dull, steady pain in the periumbilical region. And gradually over 4 to 6 hours, it gets more localized in the right lower quadrant. And if we talk about the symptoms, you have low grade fever, uh nausea, vomiting and orenia. Now, the pain gradually builds up and at one point, there could be a sudden relief in the pain and this might actually be because of the rupture of the appendix that causes peritonitis, which ultimately, again causes diffuse abdominal pain. And we talk about how to diagnose appendicitis in a bit. Ok. Again, this is a very good slide which tells you about the clinical features of appendicitis. So it starts with abdominal pain, which is very unlikely and then goes to the right leg fossa and then it becomes persistent. Now, we talked about how the appendix could be in several positions based upon the tip of the appendix. So, in retrocecal appendicitis, because the appendix is behind your cecum, it can actually cause flank pain, which mimics pyrone nephritis. It can also cause back pain, which causes diagnostic dilemma. If the appendix is in the pelvis, it can irritate your bladder and that can cause suprapubic pain. And people often confuse this with uti. So it's important to do a urine dip when anyone presents with a query appendicitis. But a negative urine dip doesn't mean that there is no appendicitis. So again, other, other symptoms could be anorexia and vomiting and further. Uh a lot of patients give history of constipation before the onset of pain. And there could be some diarrhea, especially in Children as well. And we spoke about uh how fever could be low grade and occasionally we can have uria. So this happens when the appendix is actually pelvic in position, it gradually irritates the bladder that gives you symptoms of uti such as urinary urgency or frequency. And occasionally you can see blood in the urine as well. Uh Now we all know about Murphy sign, which we see in cholecystitis. But there is a really good triad that helps in diagnosis of appendicitis. And this is Murphy's triad, which is abdo pain, vomiting and fever. Now, let's talk about the signs of appendicitis. So classically, uh there is something called is the mec point. So this is assumed to be where the base of your appendix is. So the me, if you draw a straight line between thumbs and anterior iiac spine, the me B point is about one third from the anterior sup iiac spine and two third from N and classically, it is believed that if there is tenderness on this point, it is because of appendicitis. Now, a pa uh patients could also have rebound tendons where they have more pain when you actually press and then release your hand. And this could be because of sudden release of pressure and then another really important sign you see in appendicitis is rosing sign. So when you press the left left fossa, the patient actually feels the pain in the right side. And this is because of a shift of the bowel loops that irritates the parietal peritoneum that eventually gives the pain. And if you talk about other signs, so you have two other really important signs called called is the so a sign and the sign and the logic behind all the side remains the same. It is where your parietal peritoneum gets stretched and irritated and that gives you the pain. So in the, so test, if you hyperextend the hip, it actually stretches the sore, which in turn stretches the parietal peritoneum and gives pain in the right left fossa. And the sign is where your right hip is internally rotated, which again irritates the parietal peritoneum and gives right left fossa pain. And this is a really good uh slide which shows all the important signs in appendicitis where you have rebound tendon is when you press at the me Burney point where you have ring sign positive when you press in the left left fossa. And this is the sign where the right hip is hypo extended. And this is the operator sign where the right hip is internally rotated. And this is a good picture of Robs sign for the, this is so which we spoke about how the right hip is hyperextended, which in turn, stretches and irritates the sore on the pari peritoneum. So we spoke about rebound tendon is now because all surgeons like giving names to the signs. They've given a name called Bloomberg sign to the rebound tendinus. So when, when we palpate to visit up and put more pressure and suddenly release the pressure, this causes more severe pain, which is called as Bloomberg sign or rebound tendon and appendicitis. Now, it's, it's really important to think about the differentials when anyone presents with right left FSA pain, especially in females. Because the most common differentials in females are gynecological causes of this kind of pain. So the differentials to consider are it especially the gynecological causes are ova structure ectopic pregnancy. And that is the reason it is really really important to do a pregnancy test in every female who present with tr fossa pain. And sometimes uh it is also important to consider if it could be pelvic inflammatory disease. And that is why a appendicitis is primarily a clinical diagnosis. A good history and good examination usually gives you the right diagnosis. And that is why it is also important to always ask females about the sexual history and relevant gynecological history such as any vaginal discharge, any page and that bleed any dystonia, et cetera and further renal causes are renal colic which gives you pain in the right flank. This pain radiates from the right loin to right groin uti uh and pyelonephritis as well. Which can mimic right left fossa, pain and appendicitis. Further important gastrointestinal differentials are inflammatory bowel disease, especially if this is involving the cecum. It can mimic appendicitis, but it actually most likely in 90% of cases could be Crohn's in the Cecum. And then Meckel's diverticulum, usually Meckel's diverticulum is associated with pr bleeding or sometimes it could be diverticular disease. Now, if you, if you think about diverticulitis, it is most common in the sigmoid colon. And that is why the pain is in the left, left fossa, but very rarely and occasionally cecum could have divert glands as well and these might get infected. And that is when they mimic appendicitis. And the other differentials are especially in, in Children between 10 to 15 years. Testicular torsion is a very important differential diagnosis. So it is always important to examine the genitals to complete your abdominal examination. And hepatal orchitis could be another differential diagnosis and specifically in Children, the most important differentials are recent Kenis. That is the reason it is very important to ask if the kid had any recent sore throat or any flu or, or any recent upper respiratory tract infection, which could result in swollen lymph nodes, which is called me adenitis that can mimic appendicitis. And other differentials could be gastroenteritis, uh constipation, uti intususception, intususception is very common in much much younger kids and this is usually a complied uh with loose stools, diarrhea and pr bleeding. Well, uh to diagnose this. We spoke about how appendicitis is a clinical diagnosis primarily and good history. And a good examination is is primary in diagnosing this. And for any woman of reproductive age, it is very important to do a pregnancy test because we spoke about how IC pregnancy could be uh differential. And uh we look at the white cell count, we do the PC to look at the white cell count, also the CRP process for any raised inflammatory markers. And we also do a clotting screen and a group unsa in case the patient needs to go to theater for an Appy. And we spoke about how pregnancy test is quite important to rule out ectopic pregnancy. Uh and occasionally when we do a urine dip, we see leukocytes in the urine because this is because of your appendix being in the pelvic position can actually irritate the bladder that causes blood and white cell count to increase in the urine dip. And uh yeah, we spoke about how clinical assessment along with biochemical picture, looking at the blood, the white cell count and the CRP is usually sufficient to diagnose acute appendicitis. But in cases where the differentials are more or if the clinical history and the examination is completely not fitting into the picture of appendicitis, we should do further imaging to confirm the diagnosis. So the most common and the first line investigation in appendicitis is ultrasound. Now, if we do an ultrasound, it might not actually be heavily sensitive for appendicitis. But ultrasound is a very, very, really good investigation to look at the ovaries and the fallopian tubes. And it can help us rule out any gynecological pathology in a patient with a query appendicitis. Also in Children and in pregnant patients, we would not prefer or want to do a CT because of risk of radiation. And so we usually do ultrasound as a first line in Children and pregnant patients. So if you, if you look at this, this is how your normal appendix is. The guide meter is usually less than six millimeter. And it doesn't I if you compare it with this image, this looks more dilated, the diameter is more than six millimeters. And and if you look at the wall, the wall per se looks dilated as well. If you, if you look at this, the wall is more equivocal, but in this, the wall is dilated and you can actually uh look at the lumen as well. It looks a bit obstructed here. Now, the second line investigation in patients where they're not at a risk of radiation such as patients who are not pregnant or adults who are more than 40 years. CT is a really good modality to rule out and diagnose acute appendicitis. CT is really good because if it's not hematosis, it will actually tell you what the differential is or what actually is the diagnosis in this picture. And then we spoke about how Children and pregnant women, we tend to award CT because of radiation exposure. And that is when we prefer for doing MRI if the ultrasound is non diagnostic and if you are not sure if it's appendicitis, you prefer doing an MRI before taking the patient to theater because it is better to scan a patient rather than putting them under sleep using A G, which is more complications per and if, if you look at the CT S, so this is where your, your appendix is dilated, you can actually look how dilated it is and the wall is also thickened. So if you look at this image, you can see how the surrounding the fat and the mesentary is actually inflamed and that is usually 90% of cases. Hepatitis is diagnosed on CTS, look at the surrounding fat and the me and the fat standing. And if you look at the last image, you can actually see appendicolith, which is nothing but an impacted faal or fecal stone in the lumen of the appendix. Now to diagnose appendicitis, uh we use a couple of scoring systems and the most commonly used scoring system is the Alvarado score. Uh if, if you look at the symptoms uh migrate to right eos pain, which we spoke about anorexia, nausea and vomiting, all of them get one point each. And if you further look at the signs, right? Esa tenderness has two points, rebound, tenderness or the bloom bursa and we spoke about has one point and fever has one point. And if, if you look at the laboratory tests or the biochemical investigations, leukocytosis, so raised white cell count has two points and shift to left where this increased neutrophils as well has one point. And the entire scoring system is is for 10 points. So any score which is more than seven usually is appendicitis which require operative management. So score of 1 to 4 is very unlikely. So this is where we wait and watch and observe the patient. So 5 to 6 is, is usually or maybe acute appendicitis, which we observed 7 to 8 is probably acute appendicitis and we tend to operate on them and 9 to 10 is acute appendicitis definitively and we definitely operate on them if you talk about the management. So it's divided into two non surgical and surgical management. Now, the definitive treatment, if you look at the recent literature or the recent guidelines, the current definitive treatment for appendicitis is laparoscopic appendicectomy. And in certain cases, a non surgical or conservative approach where you do a trial of antibiotics and see if they're actually dissolving or getting better. However, there are cases where only antibotic treatment has been successful, but usually you see these patients coming back with a reinfection if you can actually go on it and department where you have a couple of articles where patients with only antibody treatment have actually represented and the failure rate in one of the recent studies in the Cochrane meta analysis was 25 to 30 where patients had to come back with the B infection and had to undergo an appendectomy. So hence all the literature and the guidelines actually advise that you should offer the patient all the possible options and the complications and the different treatment currently is laparoscopic appendectomy. Yeah, we spoke about this. So now a appendicectomy can be done in two months. One is the open approach and the second is the laparoscopic approach. If you speak about the open approach, classically, you give a small incision on the neck bunny point where you believe the base of the appendix is and you uh chop the appendix out the benefits of open surgery is uh well, people argue that there are cost benefits but however, the complications of open surgery are there is increased postoperative pain, there is increased hospital stay. And because it is an open approach, you cannot look at the entire abdomen to see if there is any pus or any other peritonitis in other quadrants of the abdomen. Uh And that is why people prefer doing laparoscopic surgery, all the specimens when after surgery taken out and sent for histopathological examination because there is always a one person chance of malignancy in the appendix. Now, a really good question is what to do if the appendix looks normal in surgery, would you take it out or would you not take it out? Well, the answer to this question is you take it out even if it looks normal to you. And the two reasons for this is number one is diagnostic dilemma. Well, let's say if a patient represents with right left fossa pain and if the patient already had an appendicectomy, you would rule out appendicitis as the cause and you would think of other causes that are most likely causing appendi or, or most likely causing right left FSA pain. And the second most important cause is when you look at the appendix sometimes grossly, the appendix can look normal. But when you actually examine the appendix under the microscope, you would actually see signs of neutrophils and early appendicitis. So we always tend to take out the appendix even if it looks grossly normal. Now, before we speak about the advantages of laparoscopic surgery, let's speak about, where would you put the port in a laparoscopic, a meniscectomy? Well, because your appendix is here in the right left fossa and you would want to operate in the right left fossa. We put a 10 to 12 millimeter port in um and you put two small ports, one in the left elect FSA and one in the suprapubic region because that because that gives you a good triangle and good angulation to actually operate in the right leg Phosa and take the appendix out. Now, if you talk about the advantage of the laparoscopic surgery. Number one is, you can always take a look at the inside abdomen, which is called a diagnostic laparoscopy where you can also look at the right upper quadrant. The left elects all the nine quadrants of the abdomen to see if there's anything else that's actually causing the symptoms of acute abdomen. In this patient. Number two is reduced hospital stay. Number three is reduced pain because you, you're actually getting really minor cuts, which results in less postoperative pain. And let's say if the patient has an abscess in the pelvis or let's say in the left left fossa, you can actually do a good wash out of the entire abdomen and you can always leave a drain if you think this is much more possible infection to drain. What are the complications of surgery? So, number one is hemorrhage, which is bleeding because of injury to the plate vessel surrounding. And the most common complications are injury to the surrounding structures because you're operating in the right left fossa. There's always a risk to injure the small bowel and the large bowel, especially the cecum and your bladder is exactly quite close to your appendix. That is the reason people prefer to put a catheter and empty the entire bladder so that the bladder is not dilated. So that would reduce the chance of injuring the bladder. And there's always a risk of injury to the fallopian tubes, the uterus and the ovaries because they're in quite close proximity. And uh there's always a risk of injuring the vessels, surrounding vessels. Occasionally, if you end up injuring the cecum or the ascending colon, you might have to do a bit of bowel dissection and bring out a stoma. But this is extremely rare. And occasionally if you think clinically this is appendicitis and you decide to perform an appendectomy. And when you go in, you can actually see if there's a tube of ova and apsis or if there's any ovarian cyst or the, if there's any ovarian torsion or ruptured ovary. And that is when you would have to take out ovaries and tubes. And that is the reason when you consent the patient for, uh, appendectomy, you always tell them the chances of bowel dissection and stoma and the chances of oophorectomies as well and tubectomy as well. And the later complications could be the postoperative pain, uh, the wound side or the surgical site infection sometimes in laparoscopic surgery because you put a port through the rectus sheath, especially the little port. It is really important to thoroughly close back your rectus sheath. Otherwise bowel or omentum or me, you could actually herniate through the port site. And, uh, quite rate complications could be a deep vein thrombosis or pe post any kind of surgery because the patient is immobilized and put to sleep under chair for quite a while. And if we talk about the complications of appendicitis per se, we spoke about how acute appendicitis could gradually dissolve in perforation that could result in peritoneal soiling and covering of the pus inside the abdo cavity that causes peritonitis. And there's a 3 to 10% of surgical site infections depending on the degree of how inflamed or how bad the contamination of the peritoneum is. And we spoke about how the appen appendix could perforate, but the omentum could get stuck around it causing an a appendiceal mass. And we spoke about how sometimes there could be multiple pelvic absence because of a perforation of appendix itself. In these cases, if if there are a lot of pelvic or abdominal apsis cavities, we can always consider speaking to the interventional radiologist about putting a drain before you plan any surgical intervention because it might be really difficult to drain out and wash out all abscesses if you speak in detail about the appendicular mass. So this is where your appendix perforates, but it doesn't cause peritoneal contamination because your omentum and the small bowel loops are very demas and they added around the perforated appendix. When you examine the patient, you can actually feel a small mass in the right left fossa as well. And usually because everything is so edematous, we tend to avoid doing an emergency appendicectomy in these patients, you treat these patients with antibiotics and schedule them for an interval, appendicectomy after six weeks. Well, the only reason is there is always a higher risk of injuring your surroundings because everything is so stuck and edematous. Well, I've got a couple of questions and, well, if you guys can answer these questions in the chat and if, if you can put out a poll for these questions, that would be really great. Well, I've got the first question here. Well, which of the following is not a typical symptom of hepatisis. And options are vomiting, fever, right left, fossa pain and hematosis. Let's see what you guys are actually answering. I think most of you got the answer right where? Yeah. Well, I can see, I can see d getting the most number of votes. But like we spoke about, you have abdo pain, you have fever, you have nausea and vomiting and hematemesis is where there is blood in the vomiting. It's quite unlikely to happen in appendicitis. It's, it's one of the most common symptoms in any kind of upper gi bleeds. Well, 90% of you have heart disease. So that's good. Let's move on to the next question. Well, the next question is, what is the most common position of the appendix? Is it pelvic? Is it retrocecal? Is it preileal or is it postal? Let's see. What do you guys think about it? We, well, we spoke about how the position of the appendix depends on the tip and not the base. Well, I'll, I'll display the question again. Yeah. Mhm. Well, I can see a lot of you see option two is the right answer. Well, you guys are right. The most common position of appendix is retrocecal. Well, if you look at this, the base is constant and if you, if you look at the tip, it, this is the terminal ileum that is going into the cecum, the tip could be preileal, postileal or paracecal or Retrocecal. And you guys are right. Retrocecal is the most common position of the appendix, right? Yeah. Uh, well, we spoke about but there's a lot of debate about what is the most common position. Uh But then a lot of consensus and a lot of literature says that Retrocecal, 65% followed by pelvic, 20% are the most common positions of the appendix. The next question is, what is the most common malignancy of appendix? Is it carcinoid or neuroendocrine tumors of the appendix? Adenocarcinoma? Is it squamous cell carcinoma or is it a mixed cellularity? I'm gonna display the question for a bit and see what you guys are answering. I'm gonna wait for a bit until we get a few more responses. Yeah. Well, 60% of you have said it is carcinoid tumors, which is the right answer. So, Carcinoid tumors or neuroendocrine tumors are the most common malignancies which can occur in the appendix. And occasionally these malignancies can obstruct the lumen of the appendix and present as appendicitis. And that is, that is how these malignancies get diagnosed in the first place. All right. Well, the next question is which of the following conditions is the contraindication to perform an appendicectomy. Number one is perforated appendix. Two is acute appendicitis. Three is a morbidly obese patient and four is diabetes involving the cecum. Well, let's see what you guys are answering. I'm just gonna wait for a couple more responses. So I'm gonna display the question again. Yeah. Well, I can say about 80% of you have answered the IB involving cum and that's the right answer because if you perform appen appendicectomy in a perforated appendix, we would perform appendicectomy in an acute appendicitis. And well, we would perform an appendicectomy even in a moly obese patient. If the appendix is inflamed and the only indication where you wouldn't perform an appendicectomy is if it is IBD involving the CECUM, which is most likely Crohn's right. And the next question is when imaging is deemed necessary to confirm appendicitis in Children with atypical or equivocal findings, which of the following imaging studies is the safest. And the options are contrast enhanced ct abdomen, contrast enhanced MRI of the abdomen. Three is ultrasonography and four is abdominal X ray. I'm going to spare the question for a bit. Let's see what you guys are arms strength. Well, I can see option three, ultrasonography has got the maximum number of responses and it's completely right because we spoke about how ultrasound can be a really good first line investigation to look at patients who present with right left fossa pain, especially in Children and pregnant females because we wouldn't want to put them through a massive amount of radiation. Well, next question is, where is the mcny point or the mcs point is located at? And the options are around numb? Two third from the anti iliac spine and one third from numbly or is it one third from the A SI S and two third from, um, and if it's the right upper quadrant, mm I'm gonna look at what you guys are answering. So, well, I can see a lot of responses for option C which is one third from the acis and two third from the um which is exactly right. So if, if, if it was a straight line from your um to the anterior iliac spine, it the base of your appendix is believed to be at the me burn point which is one third from your A I of your pubic bone and two third from the um next question is, will this on is a guess work? But then this is the recent literature update. I just wanted to let you guys know what this could be but feel free to guess the number. What is the individual lifetime risk of appendicectomy for an individual? Is it 5.6? Is it 8.6? Is it 16.6 or is it 20%? Well, this is based on recent literature and recent meta analysis. I'm gonna display the question for a bit. Well, let's see what you guys, I think your mother. Well, I can see a lot of people, uh, have voted for 5.6 and 16.6. Well, as a matter of fact, the literature says that the initial risk of a patient having an appendicectomy done in the entire lifetime is actually 8.6% which is option two. And that is based on recent literature and recent corrate meta analysis. All right. The next question is at what age does the incidence of appendicitis? P? Is it infancy? Is it adolescents? Is it adults or is it elderly people? Well, let's see what you guys are answering. It's awesome. Well, let's see if you guys are on. So, yeah. Well, II can see every one of you has actually voted for option two, which is the right answer. We spoke about how appendicitis is, is very common between the age groups of 10 to 30 even in this age group, 10 to 20 is the maximum patients present with appendicitis, which is the adolescent and the teenage. The next question is, what is the fibrotic structure stricture of the appendix indicative of, of fibrotic stricture? And options are, is it gangrene? Is it appendicular abscess or is it actually dissolving inflammation of the appendix or is it Luminal obstruction? Let's see. What do you guys think about this? Well, you guys are killing it. I can see 100% for option C should I wait for more people? I'm gonna wait for some more responses. All right, let's talk about it. And so any kind of inflammation in the body usually heals by fibrosis. So I if you do end up seeing a fibrotic stricture in the appendix, it is because of dissolving inflammation of the appendix. So, option three is the right answer. Well, that is actually true for any kind of inflammation in the body where your body responds with fibrosis and counters the inflammation. And the last question, what is the usual composition of the mixed growth associated with appendicitis? Is it a mixture of obs and anaerobes or is it fungi or is it gram positive cokey or is it viruses? Mm. All right. Let's see what you guys think about this. I'm just gonna wait for some more responses, but I can see about 80% of you voting for mixture of aer robes and anaerobes, which is the right answer. So usually it's, it's, it's a mix of both gram positive and gram negative aes and anaerobes that actually involve the infection of your appendix. And that is the reason when you're giving someone antibiotics for early appendicitis, you actually give a mixture of antibiotics to target both Aeros and anaerobes. Well, well, let me ask you in the chart if you can just type for me, what antibiotics do you think? Are you gonna give to treat appendicitis if you're giving this as a conservative management. I'm waiting for answers in the chart. So, what, what antibiotics would you guys give to treat appendicitis conservatively if, let's say the patient says no for surgery. Well, I can see, I can tell by two answers. Cox and Metrol oxic. Any more. Any want us any more guesses or any more thoughts? Right. Oh, yeah. Ok. II can see one more that says Oxy Metro. Well, oh, well, most of you are partly right and few of you are completely right. If you talk about what kind of antibiotics would you want to give if you're treating appendicitis conservatively because we told how you need to target both anaerobes and ops. So I can see a few people on Coamoxiclav and Metro Coamoxiclav is right because it's a broad spectrum and it targets most of the ropes and they give metroNIDAZOLE because it is a really good antibody which targets anaerobes. So you either give both co amoxiclav and metroNIDAZOLE or you see if you trust with people, give amoxicillin and gentamicin to target the aerobic bacteria. And you give metroNIDAZOLE for anaerobes. But the most common answer for this is you give Comox and metroNIDAZOLE. Well, the questions come to an end. Uh I think I think we have 10 more minutes and we can briefly talk about bowel obstruction, which is another really common acute abdomen that presents in the ed. So if we have to define bowel obstruction, it refers to a mechanical blockage of the bowel, whereby a structural blockage is actually obstructing your contents from going forward and evacuating about 15% of all acute abdomen which present to the e are actually bowel obstructions. This could be a small bowel or your large bowel or it could actually be both sometimes. Well, when a part of your bowel gets obstructed, the part before it gets grossly dilated because they can't empty the contents further. And the part that is distal to the obstruction is collapsed because nothing is coming into it. And because your bowel tries to increase the peristalsis and push the contents for forward. Because of this, there is increased secretion of the juices which actually result in loss of electrolytes in into the third space. And that is why usually 50% of patients who present with bowel obstruction need good fluid and urgent resuscitation. Otherwise, they are at the risk of acute kidney injury. So you need, you need to assess that fluid balance as well, right? What is a closed loop obstruction? A closed loop obstruction is where you have obstruction at two points where let's say your bowel is obstructed at a point in your small bowel, but it, it is also obstructed at a point in your large bowel. And that is where the middle point is gonna be massively dilated. So if you have to define a closed loop obstruction is a surgical emergency, and if it is not corrected. Let's say within eight hours, there is always a risk of the segment in between obstructed parts becoming ischemic and it can gradually result in a bowel perforation, which is a lifethreatening emergency. If you look at the most common cause of bowel obstruction, the most common cause of obstruction in small bowel is additions and this is because of previous surgeries. It could be because of previous cesarean sections or previous laparoscopic surgeries, previous laparotomies or it could be because of hernia and the most common cause of obstruction in your large bowel is malignancy. It could be your diverticular disease which is most common in the descending and the sigmoid colon or it could be b less where your bowel twists on its own. And this is most common in the sigmoid colon. And if you look at the causes of bowel obstruction, it will, you can easily divide it into three categories, but it could be something inside the lumen. It could be something in the wall or it could be something outside the wall. So intralumenal could be because of G as well. Sometimes a gallstone migrates into your small bowel and obstructs your small bowel. It could because of ingested foreign bodies which usually can get stuck in the d in the duo. No juin flexure and sometimes it, it could actually be fecal impaction that is causing bowel obstruction. The new or the wall causes could be cancer malignancies which are the most common causes inflammatory strictures. Sometimes it could be intussusception, which is more common in younger patients where a so it's like a telescope where a part of your bowel telescopes into the segment behind it, it could be because of divert strictures, uh meckels, diverticulum, cecal, diverticulum as well, or tumors such as lymphoma and the exal causes are additions again, which could be because of previous surgeries because of hernias because of peritoneal mets and because of vus where the bowel twists on its own. What are the clinical features of bowel obstruction? So, the first symptom is usually the pain and this is because your bowel goes into hyperperistalsis, but it tries to push things forward and that gives a colicky or crampy kind of pain or vomiting, which is usually common in, in small bowel obstruction because your small bowels obstructed. So everything has to come out from the behind. So that is why people tend to vomit a lot. If, if it's a r distal obstruction, let's say somewhere in the descending colon, vomiting can be a late sign. And in turn, these people eventually first go into constipation and the abdomen could be distended both in small or large bowel obstructions. What are the signs of bowel obstruction? So when you examine the patient, if, if you inspect their abdomen and if you can actually find any surgical scars, it, it could most likely be because of ras from previous surgeries. Or if, if you take a look at them and if, if, if they look really cachexic or malnutrition or if there's any history of weight loss, it could be because of an underlying malignancy. Or sometimes you can actually see an obvious hernia that is causing the bowel obstruction. Uh, and then, uh, you, you'll find abdominal distention because your bowels obstructed and everything is so dilated and people can be focally tender where they are tender diffusely in the abdomen. And I if you actually, uh per the abdomen, you can actually feel a tympanic sound where it, it is because your bowel is so dilated, you can actually he well, anything that contains air is tympanic when you per and because your bowel is so dilated, you can actually listen to the air in the dilated bowel loop. I mean, your hate, you can either hear really tingling or hyper bowel sounds or sometimes there could be no bowel sounds, which could actually point that the bowels ischemic or the bowels actually not having any signs of peristalsis, which is more riskier. And, uh, in terms of labor or biochemical investigations, uh, we do a routine urgent set of bloods, but we mainly wanna take a look at the renal function and the electrolytes because we spoke about how people can have third space loss thing because of increased secretion of intestinal juices. And, and really important blood test is a venous blood gas where we take a look at the lactate, a raised lactate could actually point at bowel ischemia. So we, we take a look at the electrolytes and the lactate when we do the bloods. And in terms of imaging, well, we know more stick to abdominal x rays because even if you do an abdominal X ray, you would want to do a CT scan because you want to take a look at where the obstruction is or what is actually causing the obstruction. So, a CT scan with contrast of the abdomen and the pelvis is the imaging modality of choice. In any case of suspected bowel obstruction, people still end up doing abdominal x-rays. But then this is, is again putting the patient to more radiation because eventually a lot of them end up having a CT because ct's not only confirm the bowel obstruction, they also point out to what is causing bowel obstruction. I, if you read the nice guidelines, they actually say that in any patient of clinically suspected bowel obstruction, you should do a CT scan in less than eight hours to diagnose the bowel obstruction. Uh And the most common findings we find on abdominal x ray in cases of bowel obstruction is. So if it is small bowel obstruction, because your small bowel is more centrally located, you, you you actually find dilated loops in the central abdomen and the maximum upper cut off for dilated small bowel is three centimeters. So you actually can measure on the abdominal x-ray, uh the uh I mean the diameter of the small bowel. And you can actually take a look at the VV convents, which are a characteristic feature of small bowel. So these are nothing but just thin mucosal folds that run across the small bowel. And if you have to identify large bowel obstruction on X ray, you look at the peripheries because if that's where your large bowel is, you look at dilated bowel in the periphery. So the upper limit or the cut off for dilatation of the large bowel is six centimeters and for the c it is nine centimeters. And uh, you look at the horse ray, which are a classical circulating feature of the large bowel. So well to summarize you, you'll get the location. If it is central, it is small bowel. If it is peripheral, it is large bowel obstruction and the management is. So, the management usually depends on the causes of the etiology we spoke about. And the most important thing before surgery is you make sure that that the patient is in adequate fluid balance and you give them enough amount of fluids and you resuscitate them before you do anything else. And you know, all patients, you first do a conservative trial where you put a nasogastric tube. And the reason behind this is you, your nasogastric tube decompresses your entire bowel. And the only indication where you don't put a naso ARIC tube is when you have a proven closed loop obstruction. These are the patients who are at the risk of bowel ischemia and these are the patients who require the urgent surgery and there is no indication to try a conservative management in there. In only other patients where there are no signs of ischemia or perforation. You, we initially try a period of conservative management where you put the patient little by mouth and you put a nasogastric tube to decompress the bowel. And this is called as the drip and start method. And you ensure that the patient is receiving adequate amount of intravenous fluids. And you cut the electrolytes if there is any derangement and we tend to put, put a urinary catheter because we wanna look at the fluid input and output, which would help us decide about the fluid balance and to give the med and as well. And in patients who we are trialing conservative management. So these are the patients who do not have any signs of ischemia or perforation. We we can give a water soluble contrast and you can actually take a look, look at the contrast. So, and you'll repeat an X ray in about six hours to see if the x-ray is actually crossing, if the contrast in x-ray is actually crossing the point of obstruction. And if it is, this is actually a very good prognostic sign and this could mean that the obstruction is resolving on its own and surgical management So the patients in whom surgery is indicated is patients with ischemia or we spoke about patients who have closed loop obstruction, which is obstruction at two different points. Uh And of course, which requires surgical correction such as patients with a strong related hernia that's causing obstruction or patients with a tumor. So, these are the patients who definitely need a surgical management and in patients who you have trialed a conservative management using uh a nasogastric tube. If these patients are not improving in 48 hours, we offer them surgical management. And usually again, the nature of the management would depend on what the underlying causes. Let's say if it's a hernia repair the hernia and if, if a loop of the bowel is stuck in the hernia sac and if it is to make you dissect it, so again, the, the surgery would depend on what the cause of the obstruction is. So, let's say a patient has a descending colon tumor that's causing bowel obstruction, we dissect the tumor if it is resectable and we, we do do not join the loops in acute phase. So we end up bringing a loop of the bowel as a stoma and but you can gradually later reverse the stoma and join it back as an elective procedure. Once you are over the acute phase and the complication, we spoke about how bowel obstruction could result in bowel ischemia or bowel proliferation. And this can result in terit of the entire abdomen. And patients are also at a risk of uh acute kidney injury and end organ injury if the fluid balance is not adequately managed. Mm. Well, that is it. And any more questions about bowel obstruction, I'm happy to answer in the chart or just any questions about lower gi uh surgery in Children. I'll just give it a couple of minutes. But um, just in case if there isn't any questions, thank you so much, Doctor for the chat. Um, sorry for the talk. We had an amazing time. Definitely learned a lot and found the call. It's really useful. Um I've also put the feedback link as well if anyone wanted to provide any feedback so you guys can get your certificates. That'll be amazing. But yeah, um, if there's no questions and that will conclude week eight for our teaching series. And if possible, I just love to say thank you to Doctor Murray for, um, everything today.