 So this is something very, very important, we have read about Charcot's triad and you know Reynard's pentad in our textbooks. So what happens is either there is a biliary obstruction which is causing sepsis because of even a small stone can cause, and believe me, this is one of the most gratifying procedures to do an endoscopy form because the patient is having a BP of 76 tall, heart rate of 130, 140 is about to, you know, become very sick. You go in the middle of the night, do an ERCP, not all you have to do is go through the ample of water, put a stent here, bypass that stone, you don't even have to remove it at that time. The cholangitis is solved, next day morning you see them sitting up and having coffee, most gratifying. You would have died in the next 6 hours otherwise. So common causes for cholangitis are bile duct stones which slip down and block the biliary tree here and they cause obstruction to the biliary tree causing cholangitis. The classic triad of jaundice, fever and right upper quadrant pain is our Charcot's triad. If this is associated with hypotension and confusion, that means it is progressed further too, then it's called a Reynard's pentad. What do you do in such cases? You do, this is all, what are the signs and symptoms, we will not go into this. We use an endoscope, we go in, this is the ample of water, we inject and die. You can see a lot of gallstones here and something blocking here. At this juncture all you need to do is not remove the stone, just put a stent in and get out. So that stent drains the biliary tree because the biliary tree is a very narrow and small cavity. Even a small increase in pressure causes a lot of separative bacteria maya and sepsis and death. So drain the system with a small, with a small stent there and things should be sorted out. This is how a stone is pulled out, a yellow stone through the biliary spring protamine, this is the cut of a sphincter and the stone comes out here, so is the biliary drainage happens and the cholangitis settles. You can see multiple stones being pulled out here. This is just a diagrammatic representation, diurnal bulb, D2, ample of water, this is our sphincterotome, this is the wire that is used to cut the sphincter open. Go in here, put a balloon and pull this stone out. This is how a cholangitis is treated. The other emergency that we come across commonly is hepatic encephalopathy patients who have cirrhosis present with altered sensorium or drowsiness. This happens because of failure to metabolize ammonia by the liver, it bypasses through the photosystemic shunt and affects the brain and causes altered behavior. Most encephalopathy patients are presenting with drowsiness, but we have seen rare scenarios where they present with Parkinson's like symptoms where we confuse it with the SDH or other symptoms and rarely they present with aggressive nature, very rarely. So we should keep that in mind. So this is what happens in hepatic encephalopathy. You should remember that the precipitating events and ask for all these things, presence of history of constipation, presence of any fever, presence of any dehydration in the form of any acute gastroenteritis, potassium is an element which when it goes down precipitates encephalopathy, presence of melina and use of any opioid medications like Tramadol are given Tramadol, parastomol combination to liver disease patients for pain. Next day they come back with encephalopathy. So you don't know the functions of liver in many patients. So even a small dose of opioid they can land up with hepatic encephalopathy. So this is a various classification of hepatic encephalopathy you don't require to know. Only thing is that in underlying liver disease you should be very careful in giving opioid medications. When they present with altered sensorium, just look for these precipitating factors and try to roll them out. So these are the therapies, what are the therapies you try to correct the precipitating factor. Most importantly supportive care airway protection, treatment of precipitating cause, lactilose is the gold standard. As of today it is still the gold standard followed by the recent addition about five years ago of the facsimile to this armamentarium. So people who get hepatic encephalopathy not only keeping them in lactilose, but keeping them on a facsimile 550 milligram twice a day landmark NEJM article keeps or revents the recurrence of hepatic encephalopathy. But in India we use a dose of 400 milligram probably because of the lesser body weight of our patients. And this is some key which I want to tell to most of the practicing people the concept was that limit the protein intake. It is not true. You can give them one gram per kg of protein easily, carbohydrates and other things as usual but don't give them too high a protein more than 1.5 gram is not indicated. And for the long term management of hepatic encephalopathy the underlying liver disease should be treated. That is the key there. So this is one of the things that elderly people come to us with. This is my last emergency. I have categorized it as an emergency because of the pain and the trauma that the people who present undergo with this form of a presentation. So they come to us with fecal impact, elderly people, bedridden people, they come, the attenders bring them saying this pan is having diarrhea is passing 10 stools a day. I mean you ask them is it really 10 stools or is it only small quantities of stools. All you need to do is put your finger in the rectum and find out whether this guy has got an impacted stool presenting as a pseudo diarrhea or it is a real diarrhea. And 90% of the times it will be an impacted stool. The water will be just flowing from the side and you will be passing 10, 15 ml of stools. So all it needs for you to do is to do a rectal examination. Billion law probably written a century ago is saying is still true. If you don't put your finger there you will end up with your feet in the shit. So you should do a PR examination. Make sure that the digital evacuation is done. It's one of the most gratifying procedures. Patients feel really comfortable after doing a rectal evacuation of stools. So the method is to just put them in the same position. Use a gloved hand, go in, digitally break the stools and probably give an enema. With this I would like to stop here at whatever GI emergencies I thought were clinically relevant. I would be more than happy to take any questions. Isipajal, varicea and bleed. Any role for COVID law in ascending? In acute bleed there is no role. If you see a large varix in a person who has come with liver disease and the varices are showing red color signs, both a banding and putting them on beta blockers in the form of carbadolol or propanolol has found to have equal results in the form of prevention of bleed. Putting an acute bleed setting no role for carbadolol or beta blockers. It has to be an endoscopic therapy, either one of these octrotide somatostatin which we used to infuse in the past or tarliprasonazum. Sir, this law of the intestine that is sharp objects coming out without causing any problem with the intestine is quite interesting. Very interesting. Very interesting. How can sharp objects spin and sharp things come out without causing any problem? Well, the concept is not clear to anybody but the thing is that when digestion takes place and the food bowlers which gets digested moves down, it is thought to be moved in a vertical fashion, especially the sharp objects. We don't know why. That's why it's called the law of the intestine. Without a reason we have not much of perforations even it's a sharpness. Very interesting but that's the truth. Many things I think nature solves on its own. Previously all foreign bodies were attempted to be removed, go in the stomach, do all the kustia and get it out. But nowadays we leave it alone and it comes out in the stomach. So we learn as we go by that the nature is more powerful than our medicine. And do you have cases in spite of all the investigations, the acute abdomen, the cause of the pain remains unknown and it becomes a mystery and difficult to manage to have such experience? Yes, sir. Yes, sir. In my last 12 years I have seen a few acute abdomens which boggled me without reason. That doesn't pick up anything, CT is normal, everything is fine, still there is pain. Yeah, then we have to look at the general condition of the patient. If the general condition of the patient is stable, then it's probably a functional abdominal pain. If the general condition of the patient is not good, that is, he's hemodynamically unstable, he has severe pain, then we have to look at these rare metabolic causes like lead intoxication which can be a possibility, porphyria in which everything will be normal. There are such people with hyperparathyroidism where there is increased calcium, the groans, mones and that, you know, that classical saying. So these are the things that we have to look at. But yes, once a year you do get such patients. Well, it makes us more humble every day we practice. To hand over a moment to Dr. Deeraj.