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Hi, everyone. Um, thanks for joining. Um, we're gonna wait until two or three minutes past seven just to let some people, um, just to give some more people a bit of time to join. Um, if you can hear me, could you just put a yes or some indication in the chat, please? Thanks. And you can see the slides as well? Ok, thanks. Hi to everyone who's just joined. Um, um, I think we'll, um, probably make a start because there is quite a lot to get through. Um, so just to introduce myself, I'm Sivani. I'm a final year at King's. Um, and today's session is gonna be on epigastric pain. So if, if you've not joined Code Blues, um, sessions before then what happens is there's around 40 to 45 minutes of be on a specific topic and then afterwards you guys, um, sort of go into breakout rooms and then can do a practice relating to the topic. So, um, I will, I will be monitoring the chat and I have made this, um, as interactive as possible. So if you guys, um, can use the chats, um, to sort of type in answers and stuff and that would be great. I will um II can see the chat. Um, and I think we'll make a start. So today, so just a disclaimer, uh is that these are our partners and that this teaching doesn't replace informal teaching from your university. Um So today we're going to be going through um sort of the structure of an abdominal focus history, some of the red flag symptoms of an abdominal histories, sort of focusing on epigastric pain. I'm gonna try, we're going to generate a list of potential differentials um of epigastric pain and we'll go through them individually, we'll briefly touch on a abdominal examination findings. Um We, we've also got an abdominal focused at E OY station and then at the end, we've got um a few slides on how to explain and counsel patients on um preparing them for colonoscopies and OG DS. So we'll be looking at three different OSK station types history um at E and then a counseling. So, can people just put in the chat? Um, what sort of things they would ask in an abdominal history? What sort of key points they want to ask about? Thank you. Yeah. Great. Exactly. So, Socrates, any, any pain that people have anything else? Ok. That's right. So, in terms of what to ask in an abdominal history. So, of course, you're going to introduce yourself. Oh, yeah. Great. So, nausea, vomiting, difficulty eating and drinking, any dyslexia. Great. Yeah. So the structure would be, so you'd introduce yourself. Um including ice, people like to put ice in various different places in the history. Um At the beginning is fine, sort of in the middle is fine as well as, as long as you ice the patient and then ask about the pain. So a lot of um details about the pain. Yeah, great. Also about habits. Thanks, Jamie. Um So the cataract sticks of the pain, the sides of the pain when the pain came on. Um What the pain feels like all of this can give us a lot of information about um the etiology of the pain. And then you want to do a systems review. So that's the gi specific one we'll go through. What questions do you want to ask specifically about the gastrointestinal symptoms? And then a general systems review as well to see if they're systemically unwell. And then you want to ask about past medical and past surgical history. Any drug history, including any allergies and then social history, smoking, alcohol and diet can be quite relevant in some of the epigastric um presenting complaints and then any family history and then of course, travel history, which is quite easy to forget, especially if they've come in with say um an infective diarrhea or something. All right. So we've mentioned the Socrates for pain. So just recap. Socrates stands for sight onset character, radiation, any associated symptoms, the timing of the pain whether it's constant, whether it's intermittent, what are the exacerbating and leaving factors and then the severity usually on a scale of 1 to 10. And so what kind of, what kind of questions or what kind of symptoms do you want to ask the patient if you're doing a gi focused systems review? So think about the GI system, it's from the mouth all the way down to the anus. So what symptoms would you want to ask the patient about? Yeah, great change in bowel habit, yellowing of skin. Yeah. And some previous episodes. Yeah. So that would be in your sort of presenting complaint or history, presenting complaint to see if there's any triggers for what they've come in for. Um Yeah, so say they've come in with abdominal pain. What other sort of symptoms that they can? Yeah. Can they pass wind? Yeah, great. So you essentially want to ask about symptoms from head to toe. So, starting in the mouth, you want to ask if they've got dysphasia, which is difficulty in swallowing if they've got any ulcers in the mouth. Because then that can sort of lead to um, you thinking about IBD, they've got any nausea or vomiting and don't forget to ask about if they vomited any blood and then dyspepsia, which is actually a heartburn or feeling of indigestion, jaundice, as someone said, um, and then is there any abdominal distension? Um, if they've got any new onset or recent diarrhea? Or constipation. So that's your change in bowel habits. If they've got any diarrhea, that's pale stools or any other changes in, um, stool color, if they've got any E pr bleeding, and then to distinguish that between fresh bleeding and Melena and ask a bit more about the blood in the stool as well, whether it's mixed in or whether it's on the toilet paper and then you're gonna ask about pain. So, the ones in red are your red flag symptoms for, um, abdominal hi aching and then the ones underlined, um, on this slide are then the epigastric pain sort of relevant symptoms that you'll ask about. So that's nausea, vomiting, dyspepsia, jaundice, any change in color of a stool melena and then abdominal and chest pain because, um, the agastric region is quite close to the chest. So sometimes patients can complain of chest pain. All right. So, just to sort of put this all onto one slide. So your abnor red flags that you want to always ask about is if they've got any change in bowel habits, pr bleeding, dysplasia, painless jaundice, which we'll touch on later, any appetite loss, any unintentional weight loss, um, any fatigue or fever. So, these sort of last four points are your, um, are your indicators to see if anyone's systemically unwell and if there's something more sinister going on? All right. So, abdominal examination, what sort of things would be, how, what sort of things are we gonna do and what sort of things are we gonna look for in an abdominal examination? Yeah. Infection, palpation sensation. Yeah. Great. So, you'd also not forget the peripheral, yeah. Masses and pain. Yeah, exactly. So, you'd find that on palpation change in skin color, color. Clubbing. Yeah, exactly. Garden. Great. Surgical, yeah. Surgical scars. Yeah. Great. All right. Great. Perfect. So, peripherally you're going to be looking at the hands. Oh, great. Spider Nevi, gynecomastia. Ex hair loss. Yeah. Amazing. So, yeah. So before you go on to the abdomen, you can look at the hands, the antecubital fossa, the axillar face want to feel for the lymph nodes, especially in the left supraclavicular fossa for vers node as that can be enlarged in gastric cancers. And then you'll also want to inspect the chest and uh inspect the legs and um sort of press on the legs for any edema. And then you would go on to inspect palpates, PCO and auscultate, the amen. So you want to do it with the patient lying flat to help relax the abdominal muscles and then you'd inspect. So you're looking for scars as someone said, any visible masses, if there's just any obvious abdominal distension, um and then they need distended veins, suggestive of portal hypertension and then you wanna palpate. So you want to palpate your your nine regions. Um and a as you palpate, you wanna look at the patient's face to see if they react or flinch um to see if they're experiencing any pain. So you're gonna start off with superficial palpation, then you're gonna do deep palpation and then you're going to palpate specifically for the liver and the spleen and s somewhat the bladder, but that's more percussion. Um And so you'd ask them to take nice deep breaths in and then you'd sort of um try and feel for the liver border or the inferior border of the liver. Um When pacing for the liver, you can also elicit Murphy sign if it's relevant. So, does anyone know what Murphy sign is? Um, what that indicates a positive sign? Yeah, exactly. So, acute cholecystitis, so it's essentially where you're palpating the patient's right upper quadrant and then you ask them to take a nice deep breath in. So you do that when you're, when you're palpating for the liver anyway. And if it elicits tenderness, then that's a positive Murphy sign. And then if it's relevant, then you can put us for ascites, you want to build up for the kidneys, feel for the abdominal aorta and then a tape for a new uh bruise and to identify bowel sounds. So, in terms of um, when someone comes in with abdominal pain, it's really important to um know where the pain is because then that can tell us or sort of guide us in the general direction of um what is being affected. So you've got the nine different regions, you've got the right and left hypochondria, the epigastric region, the right and left lumbar, the umbilical and then right and left a fossa with the hypogastric or the suprapubic region at the bottom is number eight. And um this corresponds to sort of the different um in the picture on the left, you can see the different organs that you would find in these regions. And then on the right, you've got the sort of different presentations and different conditions that you would expect. Um uh um that you would expect to see in a patient presenting with pain in that area. So, in this talk, we're gonna be focusing on the epigastric region and we're gonna be focusing mainly on the stomach, the pancreas and the duodenum. So the one the conditions that we're gonna go through today are gastroesophageal reflux disease, gastritis, peptic ulcer disease, gastric perforation, and then gastric malignancy and pancreatic malignancy. Yeah, if anyone has any questions at any point as well, feel free to put them in the chart. So, gastroesophageal reflux disease or go, this is when gastric contents enter the esophagus. So that's this little arrow up here. Um And it results in mucosal injury of the esophagus. So, the causes, the main causes are those that sort of relax the lower esophageal sphincter. Um Other causes can be a hiatus, hernia or delayed gastric emptying. Um, and impaired esophageal uh impaired esophageal occurrence. Um So what sort of risk factors do you think um can cause increase in abdominal pressure and can lead to a higher risk of GERD. There are two main causes of increased abdominal pressure. So, constipation you can get increase in pressure, but we talk about more in the epigastric region. What would you expect? So, obesity, definitely. Ok. And then pregnancy as well. So quite a lot of pregnant women um experience go and then other things that can lead to or increase the risk of go are lifestyle factors like smoking, alcohol, um, coffee or overeating and then drugs and specifically drugs that relax the low esophageal sphincter. So that's anticholinergics, nitrates calcium channel blocker. So anything that sort of relaxes smooth muscle, um nsaids and aspirin can also increase the risk of GERD because they have the added effect of increasing acid secretion as well. So the presenting complaints that people would sort of usually come in with are heartburn or dyspepsia as we call it. Um, and acid taste in the mouth. Um, dysphagia, which is a red flag. So if anyone um over the age of 55 I think it is if they've got dysphagia, then that's a an immediate referral. Um, and then a chronic cough and which is, um, actually because there's a known relationship between asthma and go. So when lying down patients with gout are more likely to experience reflux which can then trigger or worsen asthma. So then, um, these patients have a chronic cough and then hoarseness of voice, um, is caused by irritation of the vocal cords because of gastric reflux. So, signs and symptoms, the, the signs that you see on examination. Sorry. So they have some mild discomfort in the epigastric region. But otherwise, um, abdominal exam would be largely unremarkable. So in terms of what we do for patients, um, typically there's no sort of investigations, it's a clinical diagnosis. Um, you can trial a PPI and suggest lifestyle modifications. So these include weight loss, smoking, cessation, breaking up your meals into smaller, more regular meals, avoid eating too close to bedtime, raising the head of the bed, um, and then reducing intake of certain foods such as caffeine spicy foods, really acidic foods, alcohol, fizzy drinks like that. And then you want to consider an O GD if they've got a dysphagia and they're more than 55 or if they've got any of the alarm symptoms that stands for anemia, weight loss, um, anorexia, recent onset of these symptoms and then any melena or um, hematosis. All right. So, moving on. So this is, so we've got gastritis. So that's inflammation of the stomach lining, the risk factors for gastritis. So you've got h pylori infections. H pylori is a gram negative bacteria. And the reason why it increases the risk of gastritis is sort of three or four fold. So it attaches to the stomach lining and multiplies in the mucous layer. So it causes the stomach to produce more acid which then damages the stomach lining. It also secretes urea, which is an enzyme that converts urea into ammonia. And this protects the H pylori from the stomach acid. And then as H pylori multiplies, it eats into the stomach tissue and can cause cris and um lead to ulcer development and stuff. So other risk factors for gastritis include excessive alcohol consumption and a typical one that you also see in sort of um progress test, questions of is prolonged use of nsaids like Ibuprofen or naproxen and aspirin as well. Stress can lead to gastritis, smoking, bisphosphonates can lead to gastritis and also esophagitis and then Zollinger Ellison syndrome, which is essentially a gastro a gastrinoma. Um You find this mostly in the duodenum, sometimes in the pancreas and essentially there's an increase in gastroin secretion, which is a hormone that in turn increases gastric acid secretion. So when you're asking about history, diet and lifestyle habits is quite important as well as drug history. Because then when, if you get all this information and the patient tells you that, oh, they do drink quite a lot of alcohol or they've been on long term nsaids, then you can synthesize this information to sort of point you towards a diagnosis of gastritis. So, presenting com um complaints that people that patients would come in with would be dyspepsia, epigastric pain and then nausea and vomiting. Um and again, so signs on examination, they'd experience mild discomfort in the epigastric region but then otherwise abnormal exam, we were remarkable. So, investigations for gastritis, you want to test and rule out h pylori infection you do, there are two tests available, you can do the urea breath test. So, um what happens is you ask the patient to ingest urea that's labeled with carbon 30 which is radioactive and then carbon dioxide is produced by the H pylori um with, because they er secrete the enzyme rese and then the carbon dioxide that we expire out is going to be labeled with this carbon 13 and then can be detected in our breath. And then there's also a stool antigen test that you could do. So this is, it, it's less invasive, it's more cost effective. Um And I think it has a slightly higher sensitivity as well, but it's, it's not to be performed if um patients been taking a PPI in the last two weeks or had antibiotics in the last four weeks. So, a complication of gastritis or where it's severe enough to damage the gastric lining, you can get peptic ulcers. So you can get peptic ulcers either in the stomach. So that, that would be called a gastric ulcer or in the duodenum. So, a duodenal ulcer in terms of the risk factors for peptic ulcer disease, um the same as gastritis. So H pylori is the main one and then you've got your lifestyle factors, your nsaids and the rarer cause being the gastrinoma. So, again, symptoms very similar dyspepsia, epigastric pain, but associated with meal times and you can have radiation of the pain to the back if the duo and the ulcer is a posterior one and then you'd also experience, you'd also experience nausea and vomiting. Does anyone know? Um, so there's a key sort of distinction between, um, meal times and the pain getting better or worse, um, between gastric ulcers and duodenal ulcers. Does anyone know what that is? Yeah. Yeah. So gastric ulcers, in fact, they get worse after shortly after eating often within 30 minutes because this is when the gastric juices are at their highest levels. And then the duodenal ulcers, which are arguably more common. The epigastric pain is worse when patients are hungry and then it's relieved by eating because um they're sort of the closure of the pyloric um of the pyloric sphincter. But then the pain usually returns 2 to 3 hours later because that's when the food and the digestive juices enter the duodenum. So this is why Socrates is really important because when you ask them what makes the pain better or worse, then this lets the patient recall whether it gets better with eating or worse with eating. So, again, signs on examination, mild discomfort in the trilin, but apart from that unremarkable. So in terms of what you, how you'd manage gastritis and peptic ulcer disease, you'd want to try a full dose of PPI for eight weeks and then review. This is if they're H pylori, if they test negative H pylori, if they test positive H pylori, you want to start them on triple therapy. So this is a PPI usually omeprazole or lansoprazole and then give them two antibiotics for seven days. So first line is amoxicillin with either Clarithromycin or metroNIDAZOLE. And then, um if that, if it doesn't eradicate the H pylori, then you give them second line PPI with um amoxicillin plus, whichever one you don't use the first time. If they are penicillin allergic, then you just give them Clarithromycin and metroNIDAZOLE. So what are some, what are two main complications of peptic ulcer disease? Amazing. Yeah, bleeding and perforation. Great. So we're gonna focus on a peptic ulcer bleeds first. So the history, the typical history that patient would come in with is worsening, epigastric pain, recent nausea and vomiting, especially if they're vomiting any blood and they may have some melena in the past 24 hours and on examination, uh they may have an increased respiratory and heart rate, decreased BP because obviously they're losing intravascular volume. Um And so you um in terms of what you'd want to do for this patient, you probably want to get some IV access, take some bloods and then um give them some fluid challenges and um blood transfusion once you've um actually confirmed that that, that that's what's happening. The definitive management it would be um to do an O GD. So um this is where you'd um try and stop the bleed um via endo um via endoscopic interventions. Um So you can either use clips, you can use um sort of heat with adrenaline and then you can use fibrin or thrombin with adrenaline. Um And then you would also start them on PPS after the O GD. Um Anyone know why you would use adrenaline with the bleeds. Yeah, exactly. Vasoconstriction. So help with it with vasoconstriction to help reduce the bleeding. Right. Right. So the second complication is gastric perforation. So this is a medical emergency. Um So essentially what happens if ulcers aren't treated the inflammatory and, and the ulcerative processes, they continue inflammation and acid um can damage the lining even more and the ulcer can deepen and penetrate into deeper layers of the gastric wall. And if the outermost wall is breached and that's where perforation can happen. So then gastric contents are able to exit the stomach or the duodenum and then enter the peritoneal C. So that's why it's an emergency. So, symptoms that patients will experience with very severe constant pain, it will start off as epigastric pain, but soon it will be generalized. They also have some abdominal distension and rigidity, nausea and vomiting as well. And then shoulder tip pain. Why would they have shoulder tip pain? What is that a sign of? Yeah, irritation of the diaphragm because um this patient got peritonitis. Um and So the referred pain from the diaphragm um goes to the shoulder so you get shoulder hip pain. Um All right. So signs on examination are that there'll be quite marked epigastric tenderness. They also have some guarding rigidity and rebound tenderness, all which are signs of peritonitis. Um They can have quite high temperatures and then they will have signs of shock. So, tachycardia and hypotension if it's really bad. So in an AK this is more likely to be a simulated A to E station because it's an emergency. So we're just gonna have a brief talk through um sort of a an example station that you could get. So a 45 year old male presents to the emergency department with sudden onset severe abdominal pain. Please take a brief focused history and perform an at assessment. So in terms of your brief history, does anyone have sort of structure to ask or to or to use uh to ask a brief history in, in an emergency setting? No. Ok. Ok. No, that's right. So the one that I use um is ample. So a stands for allergies. Um M for any medications p for past medical history is great. Yeah, thanks Jen. Past medical history. P last meal um is, is l this is really important if they, if they're a surgical patient and then e is events leading up to um them presenting to the hospital. So in this case, they've got no allergies, they're on long term Ibuprofen, they've got osteoarthritis. Um, their last meal was at 1 p.m. And then events leading up to this presentation is that they had some mild discomfort as usual. They were just reading a newspaper and then the pain just suddenly got worse. And now it's a nine out of 10. So your at E just to recap. So A is breather A not breathing A is airway, B for breathing, C for circulation, D for disability and then E for exposure. So how are we gonna assess this patient's airway? Great. Yeah. So while they're talking, so they've told you all this history really nicely. So you can assume that the airway patent and in terms of what they, what, what we're gonna do to manage it is nothing at the moment. So what sort of things are we gonna do with the still breathing? Yeah. Yep. Great. Respiratory OT SAS. Those are really vital observations. And then you could also to form more completeness. You could do chest expansion. Yep. Great, chest expansion, auscultation, deviation. Great, amazing. So this patient, the notable things are he's got a respiratory rate of 28 and his oxygen saturation is 92%. So what are we going to do for him? Oh, sorry. Yeah, thanks. So just for the breathing, we're gonna start him on 15 L um non RRI for oxygen. And then we can consider an ABG for possible metabolic acidosis if we're worried about some ischemia going on that will show a high lactate. But you can also do a BBg for that low. So, yeah. So for circulation, as someone mentions, we do BP, cap refill. Heart sounds um and also um pulse or heart rate as well. So this patient's got a heart rate of 100 and 25 BP of 98/60 cap refill was three seconds. So, what are we gonna do for him? For circulation? What interventions are we gonna do? Yeah. Yeah. Great. Exactly. So we're gonna what IV access we're putting in IV access, we might as well get some bloods as well, especially if you, if this is a surgical patient, you'd want to get a group and say on a cross match. And then like you guys said, you want to give fluid challenge, which is a 500 mL bolus. Um And then you would also want to catheterize if they, if they were going to go in for surgery as well. Great. Um So for disability, you'd want to assess their, um, the G CS, their pupils, their blood sugars and whether they're in pain or not. So the, so this patient's got a G CS of 15 pupils are equal and reactive to light normal blood sugars, but they are in pain. So you'd want to give some analgesia probably in the form of morphine um because a perforation is so painful and then what would you like to do in exposure? Yeah. Check for any rash, visible bleeding temperature. Yeah, exactly. And an ABDO exam. Yeah. Ok. Um, so you'd want to sort of feel for the abdomen, see if you can find any, any guarding any rebound tenderness, any signs of peritonitis. So, this patient's got a peritonitic abdomen and his temperature is 38.1. So, um, for this patient, you'd want to start IV broad spectrum antibiotics, an erect chest X ray. Um just to see if there's any um uh under the diaphragm which suggests a perforation of viscous and then an urgent surgical referral. And if you are gonna refer to surgery, what every surgeon would really love is if you kept the patient know by mouth and if they needed it an energy tube as well. All right, great. Um Then we're gonna briefly start you on gastric and pancreatic lignan. So, gastric cancer, again, the risk factors are quite similar to the gas to the previous gastric conditions we touched on. So, h pylori um diet, um that's sort of high in processed and preserved foods, smoking, alcohol, pernicious pernicious anemia, which is essentially an autoimmune disease where you've got antibodies to either intrinsic factor or to the parietal cells of the stomach itself. Um A family history of gastric cancers and then genetic syndromes like Blin syndrome, which is also called hereditary nonpolyposis, colorectal cancer, but increases the incidence of cancer as well. So, the symptoms that that patients can experience are dyspepsia, epigastric pain, nausea, vomiting, um, any evidence of an upper gi bleed, weight loss and fatigue. So these, so the ones at the bottom in bold are sort of your, um, sort of your red flag ones for malignancy. But again, like these are rather nonspecific. I probably mentioned these symptoms for all the other conditions as well. So again, it's about probably using clinical judgment alongside, um what the risk factors are the age of the patient, other symptoms, et cetera. So, on examination, patients may look pectic due to the malignancy. In the end, they may have uh epigastric tenderness. They may have a um left supraclavicular, enlarged lymph lymph node, which is called we's node and then a palpable mass if the gastric cancer has advanced enough. So further investigations, you'd want to do an urgent O GD. So that's a two week wait to assess for stomach cancer. Um and the two week wait would be for people with dysphasia or in patients that are 55 and above with weight loss plus any of the other three symptoms. So that's upper abdominal pain, reflux, um or dys and then lastly pancreatic cancer. So, um patients would um sort of come in with upper abdominal pain. Um This can be right, upper quadrant, left, upper quadrant or epigastric pain and this can radiate to the back. Most uh pancreatic cancers are in the head of the cancer and it commonly invades the common, it, it invades the common bile duct and can lead to obstructive jaundice. So you get, um, pale stools and dark urine. You can have a palpable mass or a palpable gallbladder. They may have weight loss, appetite loss, a new onset diabetes and then just generalized fatigue as well. So, there's a law called Cor Vos Law. I'm not sure if I pronounce that right. But it essentially says that a painless palpable gallbladder with jaundice is unlikely to be caused by gallstones. So you'd want to do a two week wait for someone who's 40 years or who's older than 40 years old with painless jaundice. The main one to keep in mind is what I put in bold. Then there's some other fine prints and knowledge around this which you can read in your own time. All right. So I've got just a few SBA S just to consolidate what we've just done. So, first one is I'm not gonna read it all out. Um, you guys can read it and then what you think the answer is in the chart. Yeah. Great. Yeah, exactly. So, it's a, it's a bleeding peptic ulcer. Um, sorry. Yeah, exactly. So, um, he's had this recurrent abdominal pain. Um, he's fainting which can, um, which can sort of, um, lead to us thinking that there's some depletion of intravascular volume. Um, he's had black Tarry stools. So that's Melina. So there's an upper gi bleed um, and he takes over the counter ibuprofen for lower back pain. So, there's been some long term NSAID use, um, which can point to an ulcer and then he's hypotensive. He's tachycardic. So, yeah. Great. Ble bleeding peptic ulcer. Second one. Yeah, exactly. So, it's a duodenal ulcer. So, it's identified by the fact that the, that the pain goes away when he eats and then returns two or three hours afterwards. Um, so that's when the sort of digestive juices and the gastric contents are entering the um small intestines. So that exacerbates the pain. Great and then got just 11 more. Yeah. Great. Exactly. So he's got pancreatic cancer. Well, that's the most likely diagnosis because he's got jaundice. There's no pain. So it's painless jaundice. There's a palpable gallbladder. So, if you remember, if you remember the law, a painless palpable gallbladder is most likely not due to gallstones. Um And then on his bloods, he's got high bilirubin, he's got a high alkaline, um and a or pe which um is a, a marker of obstruction in the biliary tree. So he has a pancreatic cancer because that can lead to obstructive jaundice. All right. So I'm just, I'm um just cautious about time. We've gotta go through counseling O GD and colonoscopy. Um And then you guys can go into your breakouts. So we're going to just touch on how to counsel first. So it's always nice to take a brief history to ask the patient see what they're concerned about because then you can tailor the explanation and the counseling to what the patient wants to know about, establish what they already know about the procedure that they're going to have, why they're going to have it, what they're going to look for trunk and check. So every time you give some information, see if the patients understood it, maybe if you've got a time and the station ask them to feed it back and then discuss any potential complications or risks and then management plan for next steps if relevant. So when we're explaining a procedure specifically, you want to talk about what the procedure is, the reason for doing the procedure, then details about what's going to happen. So before the procedure, how the patient needs to prep if they need to prep during the procedure and how long it's gonna take what's gonna happen and then after sort of any safety netting advice, um um and then also some side effects benefits and risks plus alternatives if they really don't want to undergo an OGD or a colonoscopy. So, uh the main point would be to um sort of practice explaining in a patient suitable manner um and to avoid using any jogger as well. So an O GD is what we'll focus on fast. So and ogd essentially stands for esophagogastroduodenoscopy. So it's a long flexible tube with a camera at the end and it's to look at the upper part of the digestive system, including the food pipe, the stomach and the first part of the small bowel. And, and we can watch the procedure in real time on a video. This is probably something that you would say to the patient in sort of nonmedical terms, the reason for it and explain to the patient that it's recommended for people with symptoms that don't improve. So that that's difficulty or pain or swallowing any heartburn or indigestion if they vomited blood or if they're passing dark tar like stool, and it can be used to diagnose high risk or cancerous changes in these regions mentioned. So in terms of the details, so before the patient will receive a letter with the details um about any medications that they need to stop. So you need to stop PPS two weeks before anticoagulants and antiplatelets, I think is a bit longer. And then you also want to advise them as to how many hours before the appointment they need to stop eating. So they can only drink, um they can only um drink clear fluids from six hours and then from up and then from two hours before the appointment, um they can't drink clear fluids either. And then during the O GD, it, it lasts usually around 10 to 30 minutes. They would need um written consent to continue and then they can choose between having local anesthetic or IV sedation. So local anesthetic is usually a throat brace. So it has a numbing effect and it reduces the gag reflex. Um, for patients who are a bit more anxious, you can offer IV sedation, it relaxes the patient but they will still remain awake. Um, and you would need to inform them that they would need a cannula for this for IV access. Um, they would be given a mouth guard to protect their teeth during the procedure. Um, the, the people undertaking the procedure would be using suction to clear saliva and they'd pass the tube into the mouth and they will be asked to swallow the first part of the tube and then they'd introduce air into, um, into the stomach to sort of, um, increase the, um, increase the volume. So it's easier to visualize things inside and then potentially also inform them that they may need to take biopsies if they, if they do see something suspicious. And also remember that patients can breathe and swallow during the procedure. So just to reassure the patient and then details for after the procedure, they go into the recovery room. If they've had a local anesthetic, then they just should avoid drinking for two hours and then they can go back to normal. If they've had sedation, then they need to make sure that someone's there with them, comes to pick them up and is with them for 24 hours or so. And to tell them that they can't drive afterwards as well. Someone will inform them of any findings that they find on O GD. Um, any gross findings that they find. But if they've taken a biopsy then results for those would take a few weeks. So some side effects of, or like the aftermath of an O GD, they can have some gagging or retching during the procedure just to reassure. Um, it's overall a very safe procedure. Um, after the OGD, they can have some, uh, they can have a sore throat. Um, if they've been given sedation, then they can have some form of amnesia. They can have some bloating because you're introducing the air into their gi system, some pain and then some minor bleeding. Um, if, if a biopsy has been taken, so some risks of OG DS are that you, um, there can be damage to the teeth, um, or any dental work, aspiration, pneumonia and then infection perforation. And if they've got an a, an unknown allergy to this agent that they've used or over sedation as well, it's a potential risk alternatives to OG DS. Um, so barium swallow. Um, so essentially you, uh, give the patient a barium liquid to drink this coats the lining of the esophagus and the stomach. It's noninvasive patients don't require sedation and then you x-ray them once they've, once they've drank, um, the liquid, the only downside is that you can't biopsy or remove lesions, um, in buried swallows. So that's the downside to that. And then lastly, um explaining colonoscopies. So in terms of what you, how you'd explain to the patient what it is. So again, it's a long thin flexible tube with a camera at the end and it will be passed through the anus or the back passage. And it's to look at the lining of the polo. The reason why you would do a colonoscopy, you would explain to the patient. Um it's for symptoms like blood in the stool change in bowel habits or unintentional weight loss. And it can also be used to screen for bowel cancer or other diseases too that we want to rule out and say if they've had a positive fit test in primary care, it's also important to reassure that some patients can sort of associate having a colonoscopy with the fact that they have cancer. So just to reassure them that just because they're having a colonoscopy doesn't mean that they have cancer, but it is something that they would want to rule out with the by doing the colonoscopy. Mhm. The details um about the procedure. So before you would want to um inform the patient that they need to empty their bowels for the colonoscopy to have a clear view. Otherwise the bowel may not be clear and you would have to repeat the test. So in the days before they'll be given a diet sheet of foods that they can and can't eat. So usually it's a low fiber diet with no, I'm supposed to say brand sorry or roughage. Um, and then make sure that they're drinking loads of fluids and then a strong laxative will be given for them to take the day before to clear, um, the bowels, it will cause diarrhea. And so inform them that they will need to stay close to a bathroom. And then on the day of the colonoscopy, um to ask them to, um, to not eat anything from, uh, six hours before the appointment and then only have only have clear fluids up to two hours before the appointment, wherein they after that they should not be drinking or eating anything. And so what happens during the procedure? It's usually slightly longer than O GD. So 20 to 40 minutes. So, um, again, they will need to sign a consent form to say that they understand and agree to the procedure. Cannula will be inserted, um, to give sedation. So it is usually done under sedation for most people. They will, um, the, then you'd inform them that they'd be asked to lay on their left and to bring knees up to their chest that they will, um, have a digital rectal exam prior to inserting the scope. Um, and during the procedure, the person undertaking the procedure may ask, um, may ask the patient to move the position during the procedure to help with the movement of the scope and improve, um, any view of their, of their bowels um, and then that they're going to introduce air into the colon to visualize, um, um, the wall better and that they may take biopsies and then afterwards again, because they will be given sedation to, um, tell them that they can't drive to keep someone with them for 24 hours. Someone will inform them of any findings. And then if, um, any biopsies have been taken, um, that results will be in a few weeks again, just to reassure them that just because they're having the colonoscopy doesn't mean they have cancer. But then that will depend on what they find on, on gross infection of what's um been found. So just a few side effects of colonoscopies, they can have some nausea for a little while, some bloating because of the air in the colon, some discomfort and then some minor rectal bleeding then risks um perforation, heavy bleeding and then uh infection can be introduced. And then alternatives which I don't think is used very much um is CT colonography. So it's minimally invasive. There's no need for sedation and air is pumped in through the rectum again, expand the codon and then a CT scanner takes images from different angles and a 3D model is created. But again, it doesn't, it has the disadvantage that no biopsies can be taken. Um So that, that was it. Thank you all for saying sorry when um a few minutes over. Um If anyone has any questions, please do pop them in the chart and stay for a practice. If you guys can, it will be really good to sort of stay and consolidate what um you've learnt if you have learnt anything new and then there's, I've just put the feedback uh form in the parts or you can scan this QR code over here. And if you um fill in the feed in the feedback form, you will be able to get the slides as well. So I'm just going to be looking at how many people stay for o practice. Um And if the facilitators are here, ok. So we've got five breakout rooms and how many people are gonna stay? So 12345678, got around nine people. So we can put one, two in each. So Adrian and Farina, if you would like to go to um Derrick's room, Faran and faze, I'm sorry if I'm pronouncing these wrong Faran and faze if you want to go to Isabel's room, Janella and some, but I think more people have left now. So Janella, if you want to go to Mustafa's room and then Samia, if you want to go to Rabe's room and then I'll try. Um And then I'll see if everyone, um all the facilitators have got someone in their room again. If the difficulty is trying to join the breakout rooms or anything, let me know, I'll be in this main stage for a few minutes and then I'll pop into the breakout rooms to see what's going on. Ok, Farina and Samia, did you guys want to join breakout rooms? Samia, if you wanted to go to Sophia's room and then I'll just dip in and out. I'm just gonna have a look at the other breakout rooms. Yeah. Ok, fine. Thanks Verna. Um Ravi her. Do you have anyone in your room at the moment? Uh I think my thing is working now. I was on it just a moment ago and I don't know what's happened. Sorry. Um, I'm one of the AK people. I was a moment ago and I don't know what's happened. So, do you know how to join the breakout rooms? I'll, has anyone been allocated to? So I, I'm not sure cos everyone keeps like out, but if you go to a breakout room and if there's no one there and there's more in another room, you can send one on your way. Yeah. Right. Perfect. Yeah. One sec. Let me, I'll just be right back. Yeah, Ella, if you wanted to go to Mustafa's room, um, if you can't find a breakout room with the facilitator, then you can go there. Do you have anyone in your room at the moment or?