Okay wait a sec and he's got no free fluids that's really disappointing okay right and so what did my colleagues say I think that's unremarkable yeah yeah they yeah I agree it's actually unremarkable I guess that was from the may 27 so that's 3 days ago hang on a minute let's have a at this ct scan so ct scan is like a month prior mhmm so he's had his gallbladder out his biliary tree looks alright his upper abdominal solid organs look okay and coming down into his bowel that looks alright too but I would say that was unremarkable and somebody commented on a bit of small bowel having some stuff in it have they yeah some fecalization of the small bowel it was initially reported by an msk radiologist as having an abrupt narrowing and transition. But I think that was subsequently reviewed right yeah I'm better talking about around here yeah okay I mean I wouldn't have said there was a great deal to make of that yeah however it's super nonspecific isn't it his we're not fully distending his bowel properly I mean that could be a bit of peristalsis it could be slow transit it could be so many different things yeah of course it's not high grade obstruction no okay but the the the history isn't of high grade obstruction he is able to eat and drink but just nothing solid if he he's having thick soups then that's fine but the moment he has fiber is when he and it's not even the moment he has the food it's you know 4 hours after that he gets the food hours after says to me distal small bowel okay exactly so what can we do to investigate it further well the small bowel mri hasn't helped us because we haven't got particularly good distension mhmm mhmm so we could do a different type of test we could consider fluoroscopy because if we're thinking as he got a stricture we could do that mhmm but he's only 33 that's a lot of radiation mhmm well yeah it's consideration and it's a and yeah we could also do a ct enterography mhmm where which is very similar to a small bowel mri except we're doing a a ct scan we're still giving him a lot of stuff to expand his bowel yeah and see if that how how we could investigate it like that mhmm what if we show that he's got a I guess it depends what the cause of the stricture is an adhesional stricture if he has a stricture then I guess he would have a small bowel resection I I don't know obviously I'm not a surgeon but I would have thought they're debilitating symptoms he's on a on a liquid only diet and he the symptomatology is clear that it started all after the cholecystectomy so I do suspect he'll have some sort of adhesion or sluggishness that he might need adhesiolysis for it's a bit it's a bit weird is it a bit weird it is a bit weird like the fact he's on a liquid diet that's a bit weird isn't it well we put him on a liquid diet right and that makes it better doesn't it better and he said he said he came back from his ogd he was he he wasn't told to go on a liquid diet he had a chicken sandwich and chicken salad sandwich ate it fine and then 4 hours after he vomited and then since then he's been on liquid diet he's not been vomiting it's all a bit strange but it is strange and has he got any biochemically and and no kind of has he got any raised markers of anything or you know he hasn't got celiac in the 13 he's got some transaminitis which has been stably high probably from fatty liver but his his rest inflammatory markers are normal I think I don't know if we've checked a ttg I mean we can yeah certainly he had duodenitis at the time of his endoscopy but he also had esophagitis and we suspected that was cool because of vomiting yeah but he doesn't have a gastric outlet obviously the timings don't really make sense for that either I check his ttg I appreciate that advice yeah okay I mean it's a funny 1 he's very young mhmm I might need to have a chat with a more senior colleague of mine doctor fox about this 1 because I wonder first of do we need to do any further tests probably because we haven't gone to the bottom of his symptoms which sounds so quite debilitating is he losing weight he is he's lost a stone since he's been in hospital that's concerns isn't it some of that being in hospital yeah but I want to know which is gonna be the best test for him of course whether or not we should do ct enterography yeah or whether or not we should go down a kind of fluoroscopic route to see has he got a stricture or if he's got could we do like a delayed mr small bowel give it more time is it let's just let's see what they said about the mr small bowel did he not tolerate it did he vomit up or something hang on a minute sometimes they need a men comment yeah he didn't say he was sick he said he tolerated the contrast fine and then he said it all came out the the bottom end he had a very loose stools following so it will do that's that's completely normal mhmm to have that no you should have had 1.4 liters of mannitol okay and if you drank it there's no note to say you didn't have it all hang on let me just have a look thank you it's all important to make sure we're doing the right depth hang on how do you know how to read about no it's not that 1 there's so much paperwork associated with these depths wait a sec right and so what what was it that actually brought him into hospital pain was it vomiting vomiting yeah is these things and he's had an ogd he's had an ogd yeah and that bit of duodenitis duodenitis and esophagitis you can have found a camera possibly there we go alright hello hello right hang on I'm just seeing I'm just looking at what happened with the mannitol mhmm because he would have to have a load of stuff to drink with a ct enteropathy mannitol no there we go well I can't see any note that you didn't tolerate it okay he says that he don't get okay and then I guess small bowel ultrasound is that is that strange would that help us I don't think it would help small bowel ultrasound is a good problem solving tool know if you see something that looks a little bit funny on a small bowel mri is it an inflamed segment is it not if it's the terminal ileum that's not too bad to try and look at in someone who's slim mhmm if you're just kind of looking throughout the small bowel no not particularly fine okay why don't you put a request in just so I don't forget about it because I'm not gonna have an answer for you for this for today I'm afraid no it's fine I appreciate it you put a request in for ct enterography okay put it for the attention of me doctor miles and I will discuss it with 1 of my more senior colleagues like doctor fox who has a lot more experience of ct enterography than I do I must admit I've never I don't think I've ever reported a ct endography examination and just whether or not he thinks it'd be better to do that or fluoroscopic examination yeah that's great or whether we just repeat the small bowel mri should we just do that and obviously with my gastroenterologist hat on I guess we could do a patency capsule well yeah that's another thing we could consider isn't and obviously if it gets stuck obviously we're just confirming that there's something going on there but we won't know what it is uh-huh but if she if he passed a patency capsule then his small bowel is probably working fine I think that's a good idea do why don't you do that first then it's no radiation yeah you just have a plain film don't you yeah exactly yeah the obviously yeah it's a bit of radiation but not a huge amount and then we might and if the capsule is stuck in happy yeah and if the capsule is stuck in a similar place to what it looks at maybe on the ct scan yeah then that would give us more focused idea of where something is I'm just thinking out loud here yeah yeah and then maybe fluoro is the way forward then if we can narrow it down a little bit mhmm I think your video capsule idea a patency test is a is a good idea okay before you put that okay don't put in the request for ctephropathy I'll chat to him drop me an email yeah I'll drop you an email I'll chat to I'll chat to doctor stummelt make sure he's happy with me putting in a yeah potency capsule and then I will yeah I'll come back to you I'll drop you an email with everything because it would also be really weird for him to have adhesion obstruction distal small bowel having had a lap chole that doesn't commonly happen is it not fine no not really apparently I mean if it's a complicated open chole absolutely fine no it's like but a distal small bowel obstruction from a lap chole I would have said no mhmm my other thought was if he's got pipilginal which he has has he got some kind of avm in his small bowel could that have caused some kind of stricture or something yeah honestly you don't know an ischemic stricture I guess it kinda makes sense yeah maybe maybe okay surely we'd see that on the small bowel mri surely only if the bowel was distended as well of course so we didn't get that so yeah bye I like the idea of your your patency capsule can you email me once you've had a discussion don't put the request in okay g.miles@nhs.net brilliant I'll do that interesting really interesting he doesn't need an operation at the moment does he I don't think so are you gonna do with him I don't think so I guess I'm reluctant to send someone home where we haven't made a diagnosis so I'd be keen to do that and then depending on what the diagnosis is I think of the options if there is a diagnosis to be made I would have thought that the only management will be surgical yeah yeah however if there may be no diagnosis to be made he may just start eating okay but you're going to keep him in for the moment because of his nutrition and everything him home exactly for a nutritional basis yeah alright fine so he's still gonna be ticking over as an inpatient yeah okay what was your name don't even know I'm rob rob rob miller rob rob email me I'm here next week great yeah I work from home sometimes but yeah I'll pick up my emails and stuff fantastic we'll see alright I really appreciate you looking through the images with me it's really helpful as a learning thing so thank you no worries just before you go of course hang on he has had other cts I'm just realizing now that he's had quite a few bits and bobs up right it's gonna work I just wondered why did he have that ct in march then let's have a look was it for the gallbladder I don't know hang on why can't he even get the picture without the report no you're not coming up that's really irritating hang on a minute let me just see just before you go yeah no I'm very happy to do that it's really helpful blah blah blah let me have a look myself so in march severe epigastric pain vomiting leaves stools rigors looks unwell campylobacter in december nothing there interesting right no not very exciting did he have a bit of cholangitis alright okay and then profuse diarrhea vomiting chest pain december 2023 so he's had lots of things done hasn't he this guy when did he ever score bladder out june last year okay june he says so maybe it's maybe the staff the 2 cts beforehand were kind of he had biliary pathology causing his presentation it looks like the ct from march showed signs consistent with possible ascending cholangitis let's just have a look hang on hang on and then he had an and then he had an mrcp showing cholangitis yeah I mean it's not I'll be honest with you it's not it's not wild on that ct no no what's he like is he is he normal or not you know he's had a lot of a lot of contact with health care you know he's got his own pillowcase which always worries me yeah okay he's a gastro patient yeah he's my man no he he just has yeah he's had a lot of contact with health care so he's been in and out of hospital every 6 weeks having operations for his leg for the last several years so okay right yeah yeah so he's used to being in hospital yeah but at the same time he's quite straight about it he gives a good history and I I don't doubt his symptoms I I think he is having these symptoms yeah and I don't think he would I don't think he has any desire to be in hospital really I think he's probably had enough contact with health care that he wants to be out of hospital as opposed to some patients that quite like it yeah sure understood understood I think if he I think if he's has got anything going on we need to have a look at his distal small bowel and yeah we'll go from there okay good thank you very much appreciate you alright nice to talk to you have a nice weekend bye bye then bye bye bye