 Now today I want to discuss one of the more serious conditions that we see in acute case surgery and that is acute colongitis. So what is acute colongitis? Well it's inflammation, infection, obstruction in the biliary tree, in the bile ducts. Usually a stone goes down through the cystic duct, down the common bile duct obstructs. You get obstructive jaundice because the bile can't flow you get edema, you get inflammatory response, you can get bacterial overgrowth, very serious condition because these bacteria and the bacterial products at least can get into the patient's bloodstream cause septicemia, septic shock, multi-organ failure and death. So it really is something that we take quite seriously. Who do we see it in? Well for us it's predominantly in our older population and there's a female preponderance but we really do see it across the gender spectrum and across the age spectrum. So really we see it in every patient. Not all of the patients even know that they have gallstones. They've never had previous attacks of biliary colic or colisostitis. So this is really their first presentation of biliary disease or disease or complications at least of their gallstones. Some of course have that history. Now there's one thing I want you to read. I don't want to explain everything about colongitis. I actually want you to read something. I'm going to link to it in the description below. It is a new article published. It's the 2018 Tokyo guidelines on the management of acute colongitis. They also have acute colisostitis. Please read that. The link will be below. You can get the full text there. If you want to manage a patient with acute colongitis you really have to work in a unit that has access to at least percutaneous colon geography so we can put a drain and drain the biliary tree percutaneously through the liver into the biliary tree or at least an ERCP. So you really want a facility with that or treat a patient in a facility with that that has access to these and if you don't please try and get the patient to such a facility as soon as you've initiated initial resuscitation. So what did these patients look like? Well they've got pain, they've got jaundice and they've got fever. That is your quintessential three symptoms. You've all heard about them. As the patient gets sicker and organ dysfunction sets in they are going to become delirious with a hypotension. I don't want you to memorize those things. It is just this continuum of diseases and what the Tokyo guidelines really do is they have three grades grade one mild grade two moderate grade three severe and we'll get to those. How do we diagnose it? Well the patient is jaundiced. The patient has clear signs of infection or inflammation with a high temperature and in the pain. So it's the pain, the temperature and the jaundice. We examine them, they tend in the upper abdomen. You see the jaundice on ultrasound. You can see the dilated ducts. You might even see stones in the gallbladder. White cell count might be increased. Of course these patients might show a high urea because they're slightly dehydrated. So how do we treat these patients? Number one is resuscitation. Resuscitation involves taking a blood culture, putting up intraveloce balance fluid solution that we're going to administer according to static and dynamic parameters of resuscitation. We're going to monitor how much fluid we give the patient and antibiotics. In our circumstances we initially use a broad-spectrum antibiotic and we would usually go for coamoxiclav, coamoxicillin and other units please find out in the unit that you work or what antibiotic has been identified for the use in patients with acute colonitis. Make sure that you know this and give appropriate antibiotics very early. So fluid resuscitation, antibiotics and get that blood for culture that's very important. Now you'll see in the Tokyo guidelines we can have the patients in three grades. Grade one is mild and it just says there that they don't meet the criteria for two and three. They are really going to get better on your fluid management and your antibiotics. You probably will find in those patients the stone is either floating and it's not blocking anymore or it's passed through. So really they have the relief of that obstruction in some way and together with the antibiotics that the bacteria load is managed and they improve. You can refer them for further proper management. Remember they do have stones. They do still need to removal of their gallbladder if this is the initial problem and at least some further work up as to retain stones etc. So you need to refer them but they will get better. Grade two they really are obviously a bit sicker and there are criteria for that. It usually is around age of the patient. It's about the bilirubin levels. It's about about five indications or five criteria that they list in the article and I really want you to read them. Grade three of course now we're talking about organ dysfunction. Neurological dysfunction, cardiovascular dysfunction, pulmonary dysfunction, hepatic dysfunction, renal dysfunction and and coagulation disorders. If your patient develops one of those they need aggressive fluid resuscitation. They need immediate drainage of their biliri tree and it is about if your facility can do that. Fantastic. If not, it's about aggressive fluid resuscitation. Antibiotics still get the culture and to get the patient to a facility as soon as possible if it is impossible for for drainage at your local institution. So please I urge you to read this article on the Tokyo guidelines for the management of acute colonitis. There's a section on acute colisostitis as well but very important to read. It's not a long article to read. Please read this on acute colonitis.