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For the delay, it's just my phone play playing up. So my name is I'm one of the fourth years at Preston. And today's session is gonna be about abdominal x-rays and LFT S it links in with your case on case nine, which is uh right before the pain. So before we start, so let's go for abdominal x-rays first, essentially what you want to be doing on an abdominal X ray is going back. You have to know what the normal anatomy on uh on a X ray or what you can see is. So you, in terms of muscles, you can see this right sore. I see it the shadow of the right sore. It's not uh always this visible and, but you can try to see um try to see on every single uh B xray so left. So I see it. You can see the liver edge here, the top, right, kidney, left, kidney right here. And then you can see the bones, which is the ilium and then the vertebras, but we'll go through each one in detail. Now, as always, you have to have a structure when you're going through um anything. So even chest x-rays when we did it, you have to have a structure that you will walk yourself through. And so same goes for abdominal x-rays. So this is the structure. The first thing you would like to do is that confirm the details. This is because um you want to ensure that it's the right person's chest x-ray, you've got the right person, right details, uh right date and time and then ask yourself, have you got any previous imaging that you can compare this x-ray to, to give you a better understanding of the patient? Because that might be the the abnormality that you might be seeing on an x-ray might just be the normal thing for that patient and he's had that for longstanding. Now, next ball is red. So rotation, exposure and projection, rotation you want to see or whether the patients rotated, how does x-ray look like? And exposure? You want to be able to see the small bowel and the large bowel because that's what the x-ray is going to be done for usually. So, is there any abnormality in the small bowel and large bowel? But to do that, you have to be able to visualize that. And in terms of length, it should, you should be able to see it from the diag diaphragm to the pelvis projection. Usually you have two different uh projections for abdominal x-rays. Either you have the anterior, posterior supine, uh or anterior posterior erect. You don't really have a pa a projection for an abdominal x ray like you have for chest x rays and looking at the bowel, there's a small bowel and large bowel. The way you differentiate them to on an X ray is that small bowel lies centrally and it has got these mucosal folds. Well, I'll show you that in the next slide, uh which run through the full width of the bowel and they're known as valvular contes. However, in the large bowel, we have folds but they are just outpouching, so known as hosts. Um And they don't run through the full length of the bowel itself. The rule that you need to remember is 369, which is that the small bowel normal length is about 36 centimeters, the large bowel six centimeters and the cecum nine centimeters. And that will tell you whether there, there is an obstruction. And as a result, there has been a widening of the bowel diameter. So now when you look at this, um X ray here on this, so on the first image, the black arrows are showing you that that's a small bowel. So we can see that it's lying centrally and there are folds that are going across the full length of the bowel. Then the white arrows show you the large bowel and there the folds are not ii don't know if you can see clearly on the slide. Uh But the folder is not going entirely through the, the fold is not entirely going through the bowel. Then you have two. where's it going? Yep. This shows, I don't know if I can, can you guys see that better with the Zoomed in? Maybe? OK. It's fine. Um, so this, it shows you the fold and the fold is going through across the bowl and here in the sec in the second picture. Oh, sorry. In the third picture in the slide, it's basically going through just part way. So moving on, then you can have small bowel obstruction where you have something that's impacting the small bowel. And as a result, you've got an obstruction, we said that the normal diameter is three centimeters. So anything more than that will be mean that it's a small bowel obstruction and because of the obstruction, you will see these uh lines through the mucosa even more. So these valvular conveners will be more prominent and the reasons for er a small bowel obstruction to come into place. Number one is adhesions. So, adhesions, um usually due to treatment. Sorry, one sec. Yeah, come back, sorry about that. So, uh as I was saying, adhesions, neoplasm and hernias are usually the causes of small bowel obstruction. On the other hand, logical obstruction, you will have abdo pain, you will have the distention because the fe feces is not going elsewhere. The diameter six centimeters is normal. So anything more than six centimeters is gonna be a large bowl, uh dilation, um in terms of causes, number one cause is cancer. So, any cancer in the bowel can cause a large bowel obstruction, any diverticula, you'll come across this diverticula later on in UTD and then vuls and hernias will cover that. Now. So, volvulus is when the bowel. So if you imagine the bowel wall and it turns on itself and as a result, you've got this um obstruction as well. So there's two types, either the sigmoid or the cecal sigmoid referring to the sigmoid colon. Where does the sigmoid colon sit in the bowel? So sorry, in the abdomen, which type, which quadrant does it sit in the sigmoid colon? Anyone know? So good. So Sigma colon sits in the left, lower or left ilio or your left eye face. And what that means is that because of that, it's gonna go from the left, lower quadrant to diagonally upwards towards the right upper quadrant. And that can help you differentiate in the exam itself and it gives you the typical coffee bean sign and it's a pro pro progress test uh tip here. If you see a coffee bean sign, it means that it's a sigmoid volume, the cecal volutus again, cecum sits in the right, lower quadrant and, and that's gonna extend diagonally upwards either to epigastrium or the left upper quadrant. Now, the way to differentiate them too when I zoom in a bit more here is if you look at this right. Um The top picture here in the what we call the coffee beam sign. I'm gonna try to outline this. It's this part here. This is the coffee beam sign because it looks like a coffee beam sign. It's more current in the second frame there. And it goes from the left, lower quadrant to the right upper quadrant and that's known as the sigmoid volvulus. However, in this um cecal volvulus, it goes from the right uh lower quadrant upward towards the epigastrium or the left upper quadrant. The difference is you can see, still see some posts here. So posts are, these lines are these outpouchings and you can still see them in the cecal voles and that's how you differentiate them too. Then you have pneumoperitoneum and pneumoperitoneum just means pneumo uh peritoneum in the peritoneum. And because of that, you're gonna have irritation and this could be due to a perforated bowel, perforated ulcer. Um and that's causing this air to be present in the abdomen. Now, two signss you have to be aware of whenever you, you're suspecting pneumoperitoneum number one R sign or we call it the double rule sign or football sign. Um Now, whenever you have a case of pneumoperitoneum or you suspecting pneumoperitoneum, the imaging that you want is an erect chest x-ray. So whenever they say what imaging would you like, if they haven't already given you an erect chest x-ray in the six years, say I would like to have an erect chest x-ray because that will give you the, that will show you the pneumoperitoneum more evident. So now if you see the first picture in the first picture, you have the bowel wall, uh but you can see both sides of the bowel wall. So the white part in the middle, but then you can see the bo both sides of the white arrows. And this is known as a double wall sign. You can also get the false regular sign of, um, which is not actually just regular sign, but it's just that two bowel walls just come together. Um And they're not joint or anything, but they're just, they're just sitting close together. And because of that, you see something similar to the regular side, then you have football sign, which is in the second picture and uh it's self-explanatory kind of thing. It looks like there's a football being stuck inside the abdomen. And as I was mentioning the chest X ray, the erect chest X ray that you need. It's basically here in the last picture and these bubbles that you can see all the pneumoperitoneum. And if you see this, it's bi mean on this one, it's bilateral pneumoperitoneum. Uh So you have to comment on it. And the last thing that you would like to, uh you would check for an uh x-ray in terms of the bowel is inflammatory bowel disease. And that can have three features, thumbprinting this is when uh the host thickened because of the inflammation. And as a result, you can see um, something similar to what known as thumbprints. And the reason for that could be IBD so inflammatory bowel disease or it could be due to an infection as well. The second feature is the lead pipe colon and that's basically a featureless colon that you can see. It just looks like a pipe on, on an X ray. And the last thing is toxic megacolon, which is basically your large bowel, the in, in a similar manner to large bowel obstruction, you'll have dilatation of the large bowel, but you will not have obstruction. That's the difference between a toxic me colon and large bowel obstruction in terms of diameters of the um large bones. So let's go through those x-rays. So, in the first one, what you can see, um the white arrows are trying to point to the thumbprinting. So you can see that forms are um on the large bowel and this is because of obviously the inflammation. In the second picture, you can see the transverse colon is dilated enormously. So it's even more than six. I think that would be more than 10, essentially as well there. Um But yeah, that's, that shows you that the toxic mega colon and this descending colon is known as a lead pipe colon because you can see that there's no features. It's just a dark uh pipe that's descending down. Ok. And then you have some other structures in, in an X ray, which are not really important at our stage right now. But yeah, as, as I mentioned before, the liver edge can be seen here, the kidneys and then the sores, major, uh, sores muscles, the shadows can be seen, uh, descending downwards on both sides, then you move on to bones. Um, usually in third years, six years, they unless there's an obvious fracture or unless there's a, a uh obvious deformity of the spine, they wouldn't actually ask you to uh to identify a fracture. Um You can identify if you see it, but that's not the main uh purpose of the ahe usually they would be uh it would be to look at the bowel itself. So yes, bone pathologies fractures or bone mets can be identified on an X ray, but that's more. So fourth years of not third year and then you have calcification um and artifact now because remember, white areas are highly dense on an X ray. So that's because of calcification or artifacts. And examples of these are calcified, Goldston Renal stones, surgical clips and jewelry. Let's go through pictures of each one. So on the first one, what's, where is the calcification or what is the calcification? What do you, what do you guys think is? No, it doesn't necessarily have to be the calcification. It can be an artifact done. It's in the first picture. Yeah. Good. The wire and, and that's going from like at the bottom here, uh upwards into like left, um on say left, it's not really left, upper quadrant, but yeah, to upwards towards the left hand side. And that's basically a stent that's been put into place, a ureteric stent. In the second one, you can see the kidneys. So I, as I mentioned, the kidneys are around here somewhere in the second one. It shows you both of the kidneys, what the right kidney has some stones and the left kidney shows you uh something known as Staghorn calculus, which you will come uh across later on in about week 18 of your TCD S. And then the last thing is this, this part here, which is basically a piercing someone's got and they've gone to have an X ray and that piercing has shown up on the x-ray. Now, when you present an xx ray, just have a structure at the back of your mind that goes for examinations as well, just have a structure at the back of your mind and then you can just fit in what you need to, what you need to present to the examiner. So for example, this is S and uh abdominal radiograph of name, date of birth. And then you can say, OK, no previous imaging available, what I would like you to guys to mention is that if you see any obvious um abnormalities. So for example, if there's a pneumoperitoneum and you spot it straight away, you see from the uh from the get go, I can see that there is signs of um neon peritoneum or I can see that the ball uh appears dilated and then you can move on to your structure because that means you've actually sorry, you've not missed the obvious ABN abnormality that they probably want you to comment on. And that means you, you most likely come to it later on anyway, but in case you missed about it, you, you forgot to mention it and time went away. You've mentioned it at the start or there is this new to you. So that's uh abdominal x-rays as a whole. Um I hope that was helpful. Uh Any questions before we move on to LFT S. So there doesn't seem to be any questions that's fine. You can ask them at the end. Uh If you have any questions about X or x-rays. So I'll put some re references there, which would be important for you guys if you just go through each one and there's some examination, there's some example uh x-rays that you can interpret as well and they give you the answers. Now, let's move on to LFT S. Obviously, they are an important part of medicine and uh it tells you the function of the liver. That's it's come up anyway. So we check LFT S because we want to investigate OK, what's the liver function like? Um what to we want to monitor? Ok. We've given someone medications has, is it having an a negative impact on the liver? Um, that we need, may maybe we need to stop and to check obviously for baseline before starting any medications. Some people mention that um, a liver function test is a misnomer because most of the components of a liver function test tell you about liver damage rather than liver function. Because if you look at it, a LT ast ta LP, tho those are all about liver damage. And the only thing and the only thing that, that's not about liver damage is uh I nr and the platelets. So and then you have components again. A LT AST A LP GGT and then you have bilirubin albumin um and prothrombin time we'll go through each one in turn. So the first part you um is T and est they are enzymes found within the liver cell itself and they are raised when the liver cells get damaged. And examples of these include hepatitis liver cirrhosis drug induced damage and malignancy. Now, some key um notes for you guys um I mean, it can help you in progress test because they're quick tells of what the disease could be if the T is more than the est and is risen significantly more. Uh It's usually non alcoholic liver disease ast remember as ast a sip of tequila, it points towards alcohol and because of that, um if that's raised more so than a LT, it's gonna be alcoholic liver disease. And if A LT is in the 10 thousands, that's gonna be paracetamol overdose. So you have to ask them about paracetamol. And if they've taken any paracetamol P is derived from either the bone or, uh, bilary epithelial cells. So that's why you can have different pathologies raising P and T is obviously found in hepatocytes and bilary epithelial cells. So, if you have AP and G DT both increased, it points towards something wrong in the biliary system. So there is some sort of stasis, some sort of obstruction and we call that obstructive jaundice when we come on to electron. And if there's increased GGT alone, that's basically alcohol. And if AP is the only thing that's risen and GGT is normal, that's bone cancer has it or osteomalacia, just remember like one or two reasons you, you don't need to go delve into more detail about um AP on its own, then you can compare alt and ast with P. So if there's 10 fold increase in alt, it's gonna be pointing towards liver damage. But if there's a three fold increase in AP, it's pointing towards a stasis. And if you have both of them together, it's gonna be a mixed picture. So you're just trying to identify patterns. Now, this picture here, these two pictures here, go through bilirubin metab metabolism which you guys have covered in in the first two years, but let's quickly summarize. So what happens is red blood cells get broken down and that b because they're broken down, they're broken down into heme. Then that heme gets converted into biliverdin and essentially gets converted into unconjugated bilirubin. Now, unconjugated bilirubin is everything before the liver. It, it gets conjugated within the liver itself. Once it gets conjugated, it's released into the bowel. Um And what happens is if you look at the second picture is that the conjugation is removed. So the glucuronic acid is being removed by the bacteria in the bowel and it leaves you with urobilinogen. Now, urobilinogen or stercobilinogen is the same thing. What happens with urobilinogen is most of it is converted, about 80% is converted into steroid. Now, the key part to remember is stercobilin is usually passed into in, in, in stool. And that steroid is what gives uh the stool its dark color. So if you don't have seco by, you're gonna have pale stools. And if you, if you do have stercobilin, you're gonna have the normal dark colored stools and then the rest of iogen enters, enter hepatic hepatic circulation and uh some of it gets passed into urine as UBI or Il il. And um, it didn't really have an effect on the urine color. The two things you guys need to remember. Let's see for what's on the next slide. Uh So let's do that first. So, increased unconjugated bilirubin because it's unconjugated it's before the liver, first of all, so that could be due to prehepatic causes or it could be due due to its intrahepatic. Meaning that because there's been a decrease because there's been uh damage to the liver, it's unable to conjugate the bilirubin. That's there. There's gonna be an excess of unconjugated bilirubin, an increased conjugated bilirubin. It's due to something in the liver. There's something wrong in the liver or something after the liver that's preventing this conjugated bilirubin to go away from the system or to get for the body to get rid of that bilirubin. So you have uh you uh obstructive jaundice if you have uh bilirubin, that's exceeding 50. Uh as we mentioned before, prehepatic means that there's gonna be unconjugated bilirubin that's gonna arise. Now, unconjugated bilirubin, remember it's insoluble, meaning it's not gonna be passed into the urine, then you have hepatocellular, which is obviously increased t and est because you have liver damage. And uh um you have rises in both unconjugated and conjugated bilirubin. Conjugated bilirubin can pass into the urine and make it a darker color. And because you're not having sto bilinogen going into the bowel, going into the stools, you're gonna have paler stools. And that's why you have the cholestatic picture of dark urine and pale stools. And to differentiate between hepatocellular and cholestatic, you have to look at the liver functions. If it's al T and ast, that's hepatocellular. If it's cholestatic, it's alp and GGT, then you have uh, the causes. I'll leave that on the slide. I'm not gonna go through them. Um particularly because you have TCD S later on that goes through jaundice, er, in, in two weeks, er, sorry, week, 15 and week 16. So two weeks on jaundice itself, but just remember some main ones uh for, for your, er, CCA maybe or for your progress test maybe helps. So when you have something called albumin and prothrombin time, that tells you the function of the liver itself. But the problem with Albumin is that it's got half life of 20 days. So if you want an acute insult to the liver, you're not gonna have any change to the albumin because it's gonna take 20 days for it to appear. So what we use is something called prothrombin, prothrombin time. Uh which tells you that there's been a hepatocellular injury, uh acute or chronic prothrombin time tells you uh the um if you remember the coagulation cascade, it tells you the extrinsic cascade. Um which is basically what happens is there's decreased Vitamin K and as a result, there's gonna be increased time of clotting and prothrombin time increases as well. So essentially, when you look at LFT S, look at the pattern of LFT derangement. A LT ast A LP GGT, look at bilirubin, is it raised? If it's raised, it's gonna give you jaundice if it's above 50 assess the synthetic function. So, before I finish, I'm just gonna quickly go over this slide once more. How's it going? Uh So this light here. And I just to remember that in, if it's prehepatic jaundice, you're gonna have unconjugated bilirubin rising. That's insoluble. So you're not gonna have any change to your urine and no change to your stool because your Stacy is stoy bilin is still going into the stool when you have post hepatic jaundice or cholestatic jaundice. What happens is that you have increase in conjugated bilirubin, which is water soluble. If it's water soluble, it's gonna go into the urine and cause the urine to be a darker color. And that's why you have the dark urine in cholestatic picture and you have the pale stools because you have less stir combining going in excreting into the stools. And that's why you have the combination of dark urine and pale stools. It's a bit tricky with hepatocellular because you can have a mixed type of picture. You can sometimes have normal urine but sometimes have darker urine. So there's variability in urine and uh stool colors. But what will help you differentiate is that looking at the LFT S itself? So that's I think, yeah, that's all from LF TSI. Was gonna include some examples, but II was thinking that you guys are gonna have CCA practice anyway. So it'd be helpful if you guys go through that there. But I can answer any questions right now if you have them?