Fun would anyone like a nectarine a nectarine a yellow flesh nectarine nectarine nectarine nectarines I'm more a nectarine no takers for a reduced nectarine that's part of your health care no even the health care group 54 years old 54 5 years old I'm in canada because I I don't don't live in canada yeah okay fine when are going to canada saturday that's sick but unless he's probably never he's fucked I suppose you've probably still got it from where you live there's a mr givens here 1 of your other tips yesterday and this is a gentleman with met ald cirrhosis refractory ascites and then elective tips for refractory ascites he's also got multiple myeloma and is on lenex for for that so he gets 2 lenalidomide and dexamethasone okay yeah fine I've heard of this dex is 2 mg 3 weeks out of out of 4 okay so it's a week off basically yeah 1 essentially he became very hypotensive yesterday post so the wonder was about a bit of steroid insufficiency because of dex infection because of pierced bile ducts during the procedure so he may have a bit of haemophilia yeah for sure or he could a collection or he could have a collection indeed amongst others basically he's also on spiro beta blocks like lots of reasons to be hypotensive after eating and drinking for a bit blood pressure was about 75 and he what's it now reese hey what's it now it's a 100 of it's 5 l so he gave him some steroids some antibiotics and some fluid yeah possibly a little bit too much fluids that might help really about 5 l of crestor oil for a cirrhotic patient good then unsurprisingly developed societies it's funny that isn't it yeah great initially we all put down to the fact oh it's probably just getting too much fluid however better judgment if he says no let's get an ultrasound scan just to check and he's got clots extending from his port pretty much the length of his porta vein into his tibs he's now had an interval ct scan when was this this is literally moments ago ago he's awaiting a report I'll see it then but it's not reported yeah no it's not so you've been anticoagulating him no no so we've not found out about it yet sorry as in we we what we wanted to elucidate that he wasn't having like a massive hemorrhage into his bile duct oh boy yeah that worries me how much contrast is in his in in that what that looks like a bit of a bile duct so it's not bile duct it's gallbladder well you know what mean but it's quite quite a bit of a sort of birth yeah it's a cystic duct so he's got he's got active contrast blood sugar in in the gallbladder pooling in the gallbladder pooling in the gallbladder and then aphasic biphasic it's portal venous yeah I guess it makes sense that it would be there if it's portal venous if nowhere else is the contrast accumulating just there it hasn't reached the intrathecal duodenum at all the only thing I would argue I don't know how relevant this is necessarily that poo stands out more to me yeah like it's had a bit of contrast yeah exactly no it's short and long it is a bit weird though it is quite strong poo but equally anyway it just needs to look at the report and then make a decision about whether he has can we see the aa phase still clotting that port mate oh yeah oh no although the tips looks alright though yeah the tips look really good nicely placed nicely placed and it looks like it's got normal blood in it it's got mixed contrast and non contrast blood there's your haemorrhoea it's weird though isn't it like why are you getting so you're gonna put contrast in and then it's actively it's going in in the arterial phase isn't it yeah whenever if you've enough contrast yeah it's just gonna show bright either way isn't it so because because the rapidity at which contrast moves the the rapidity at which fiber moves system vastly slower compared to the vascular system so you cannot distinguish whether that's an arterial blood or whether that's a venous blood yeah but you've looked at the portal venous phase after the arterial phase so it's going in pretty quick we saw it both the portal venous phase delayed and we saw it right now so it's as you say haemophilia is flowing in fast in the arterial phase and that looks like a clot or a stone some sort of void essentially what I would do is look at the report and panic and call the client because what we need is we need a decision about whether or not he's too flexing but if he is actually bleeding that's probably a bad idea what will ir do so they're offering a trans splenic thrombectomy no not trans splenic sorry trans tip thrombectomy so go back in through the tips and hoik out whatever clots in there that's sick isn't it yeah they can't do that they can't have ever done that before they did it for him to start with really yes well but they tipped it and then hoiked out the clot oh and then the clots were accumulating yeah they they I didn't know they'd poiked out the clot yeah so he had a bit of pv thrombus then yeah the other option and the reason they wanted the ct in the place was they might thrombolise it but you're not going to thrombolise it no that's thrombolise it and bleeding how can we stop the bleeding good question it's bleeding into the cystic duct well I mean we're also 2 non radiologists looking at a scan it's definitely bleeding into the gallbladder yeah yeah that's the call don't know how to be a radiologist to know that I don't back myself that much rob sit at the ecg you'll know that's the call back you'll back yourself enough on the radiology there's plenty of radiology in it that's definitely gallbladder but the gallbladder sat there with stones and just stones or yeah lots of lots of and then some sort of flavoid and then in this it's the cystic duct and then into the common duct and that kind of actually fits with the so if you think about what they're actually physically doing so they're puncturing it where the tip of the tip so it's like hepatic vein and punch punch punch punch brilliant through the liver and then they've gone here and then they've overdone it just overdone it ever so slightly exactly I mean could easily be how red just had a go I mean oh it's about a centimeter in the fuck pack quite badly haven't they 1 slip of the wrist so yeah I mean so they've gone a bit too far punctured the bile duct and now he's bleeding surgeons that's the thing I was thinking like it's a structural problem could you fix it with an ercp could you put a fully covered plastic stent probably yeah it's a cystic duct you'd probably tamper on the bleeding and that would fix your bumibilia problem as well wouldn't it I reckon that would be a way to do it but so that would be ercp tap bleed give him 24 hours rescan him rescan him and try the and try and he could have a ptc and tap lung bleed that way like a yeah ir intervention yeah so you have a little angiogram and then stenting it's a bit horrid isn't it and I guess also it's probably quite a tight corner like if the cystic duct comes off like this you're gonna struggle to get into it whereas from below you probably probably sure I bet it'll do bet it'll do actually fucking nothing just leave it to what happens just wait till friday and then they can talk about it a little bit and then decide to wait till monday that's haptology death by talking death by mdt mhmm honestly mhmm don't why mate when you get your hands on these scapes know once you get your hands on that colonoscope refill give up any oh I any desire to love the liver trust me no so much fun not even that bothered about doing colons oh dude I wasn't that bothered you like ogts you're not bothered I enjoy them but it's not like oh my god this is amazing favourite part it's my favourite part yeah yeah it's so funny it's a nice thing to go do that's not clinic that's not like whatever but it's not like the on the end of it yeah if you told me tomorrow that I could never do an ogd again I wouldn't cry about it oh my god I might have a look at the break fair enough so it's fine very interesting it's yes for sure very interesting yeah I'll call back on the other end you've given me you're probably +1 653763 alright no yeah and reassuring you his head he's not touching and if he's if it is a patient it's not like I think bile we're probably camping on it a bit when yeah I mean if anything blood pressure he had a bit of a bit of a drop initially and there was a reported sort of about 500 mils he's out of there really now oh right thank you no I'm I'm alright but he had a bit of hp drop in intra procedure because when he had the when when they when they I didn't realize when they do thrombectomy they take about a liter of blood yeah fuck didn't know that yeah yeah so when they do a because essentially if you've a distended portal system there's loads of grotty blood clots and whatever and it ends up being about a liter oh god so these they they basically lost about a liter of blood in in 1 go so he dropped his hp down they're like oh no this is all well explained by like the procedure so interesting what interesting case mhmm have you had any interesting cases or no I took off a really big polyp the other day really big really big really big like berries like what like grape size like like golf ball size really mhmm and sigmoid really big did you calculated did you leave a hole in the side no thankfully there was plenty of stalk good it was so nice oh so nice how do because if it's that big how'd you get like snare around it spin it around it so you just like push push push and just try and see whether go pop pop them put loads of air in them put your nose up over it put the snare distal and pull back onto it okay and kind of just fiddle it around a bit we can cut the tops off it like bigger bit oh yeah yeah yeah just cut out the bits if you want I had a I had a patient who was just referred for dysphagia and had a food bolus the other day which was quite fun how fun I was like oh that'll be why then did you put it down yeah gave it a push and it went so blah and it looks fine but it was the it was the it's me 1 of the clinical nursing hospitals michelle I think she's better if she really does but she obviously she's running with her I know well I know the people they're very like regimental and what you should be doing and she's very good at training and all sorts of stuff to interrupt I wanna give her a push I think it's a good thing I won't push hard I promise but I just went not sure not but she was never enough me I don't know yeah well she probably wouldn't she's the like lead like I think she's the barratt's lead or whatever so it's like proper experience but I don't know I feel like often when the dynamic of the nurse training the doctor is an interesting 1 possibly yeah yeah I agree but actually I think she's probably been the best trainer I've had for like technically that's so good yeah I feel like the this is how you're supposed to do it this is why you're supposed to do it all sorts of ways you get like if you get a consultant training you it's like I do it this way this is my practice this is how I do it and then like or I do it like this I'll walk somewhere exactly but then you get someone like jim gower and they all love it he was like I can't actually really explain to you how I do an ot mhmm just do it and smack that's unhelpful yeah thanks for that exactly yeah that's really unhelpful I feel like it's important but you they don't do an ogd train course they just do a training: course that means they need to train you to train up to these upper and lower tcg which is a bit weird isn't it whereas all of the clinical nursing therapists have probably done they probably only do uppers and then they call it a train the gastrostomy gastrostomy trainer course which is probably teaching you a lot of techniques about how to physically teach you that type of thing I think that to be fair we all think that's a good idea would you nice