Guess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not
Guess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not
Guess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not
Guess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not
Guess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not
Guess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not
quoteDoes he meet criteria for acute pancreatitis and based on what I showed you, We think he does↗
▶Ep 1 · 2:23
clinicalUltrasound is limited in the setting of suspected complications of pancreatitis; CT is the image of choice for complicated cases to better visualize necrosis, fluid collections, hemorrhage, or masses.↗
▶Ep 1 · 2:40
quoteSo it's not that the sensitivity is different early on, but amylase rises and normalizes much quicker than the lipase.↗
▶Ep 1 · 2:40
clinicalAmylase rises and normalizes much quicker than lipase, so in a patient presenting 2 days after symptom onset, amylase may not be the best indicator of pancreatitis.↗
▶Ep 1 · 3:00
clinicalLipase half-life is about 7 days and is more specific for pancreatic pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary disease.↗
▶Ep 1 · 4:03
clinicalThe most helpful use of ultrasound in acute pancreatitis is looking for a biliary component—CBD dilation suggesting need for early ERCP, or gallstones that change management—not documenting pancreatitis or looking for complications.↗
▶Ep 1 · 5:15
clinicalMRCP is not the most helpful imaging modality during an acute pancreatitis attack because edema obscures ductal anatomy; it is better reserved for workup of biliary and pancreatic ductal issues after resolution.↗
▶Ep 1 · 6:21
clinicalThere is no data identifying a superior pain medication for acute pancreatitis; even adult studies have not identified optimal management.↗
▶Ep 1 · 6:27
quotedon't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier.↗
▶Ep 1 · 6:35
clinicalOpioids should not be avoided in acute pancreatitis; when used appropriately, they can help advance feeds, improve outcomes, and facilitate earlier discharge.↗
▶Ep 1 · 9:01
quoteThe data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate.↗
▶Ep 1 · 9:03
clinicalEarly nutrition (within 24 to 72 hours) in acute pancreatitis is associated with more favorable outcomes: it maintains gut barrier function, inhibits bacterial translocation, and lowers the incidence of systemic inflammatory response.↗
▶Ep 1 · 9:32
epidemiologicalA 2012 meta-analysis comparing TPN versus enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, reduced surgical intervention rate, lower mortality, and fewer infections.↗
▶Ep 1 · 12:41
epidemiologicalStudies comparing NG feeds versus NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality were very similar, even in severe acute pancreatitis.↗
▶Ep 1 · 13:19
epidemiologicalThe Ekerwal 2007 study randomized 60 adult patients to eat on admission versus NPO and found that early feeding did not increase abdominal pain and decreased length of stay by 2 days.↗
▶Ep 1 · 13:43
quoteGuess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not↗
▶Ep 1 · 14:29
epidemiologicalIn a Cincinnati Children's study of 38 admissions for mild pancreatitis, early nutrition was safe and feasible, and patients who received feeds had similar pain scores to those kept NPO.↗
▶Ep 1 · 15:25
quoteI haven't found a good evidence for the low fat. However, we know that fat stimulates lipase and we don't want to increase lipase.↗
▶Ep 1 · 15:28
epidemiologicalPilot analysis showed patients with the lowest pain scores were those who ate the most fat; fat intake did not increase length of stay.↗
▶Ep 1 · 15:40
quoteThe lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat.↗
▶Ep 1 · 15:54
quoteIt's, it's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home.↗
▶Ep 1 · 19:02
epidemiologicalAggressive IV fluid resuscitation (more than one-third of 72-hour fluid volume given in the first day) is associated with reduced mortality and reduced incidence of SIRS and organ failure at 72 hours.↗
▶Ep 1 · 19:45
quotereally you've got a window and it's a 24 hours and if you don't interject then probably you lost your window↗
▶Ep 1 · 19:45
clinicalIn studies of aggressive resuscitation, the late resuscitation group received more total fluid than the early resuscitation group, suggesting a critical 24-hour window for intervention.↗
▶Ep 1 · 20:18
epidemiologicalA 2011 study of 40 patients using goal-directed management (resuscitating to urine output of 3 mL/kg/hour) showed early resuscitation with lactated Ringer's reduced inflammation markers (CRP) compared to normal saline.↗
▶Ep 1 · 20:48
quoteAnd here brings the question of should we all use LR? Again, this is one study.↗
▶Ep 1 · 22:13
quotewhen we aggressively resuscitate, there are some evidence that shows that you could actually flood the lungs and result in pulmonary edema↗
▶Ep 1 · 23:48
epidemiologicalIn a Cincinnati Children's study of 201 patients, those kept NPO with low IV fluids had 35% rate of developing severe pancreatitis, versus 4.2% in those who ate early and received aggressive resuscitation.↗
▶Ep 1 · 24:50
quoteThe classic story, since we're talking about diseased pancreas, it can't be that easy, right?↗
▶Ep 1 · 25:21
quotewhen the patients are not NPO enough time and I don't know, Andrew, if you want to comment why sometimes we get the non-specific findings or not adequate to comment↗
▶Ep 1 · 30:31
clinicalRanson's criteria have not proven sensitive and specific for predicting severity in pediatric pancreatitis when validated in further studies, despite initial promise in a 2002 Midwest study.↗
▶Ep 1 · 31:20
epidemiologicalA Cincinnati Children's prognostic tool using white blood cell count, albumin value, and lipase on admission can predict severity in almost 70% of pediatric pancreatitis patients.↗
▶Ep 1 · 32:32
clinicalAntibiotics should not be used routinely in mild acute pancreatitis or in severe pancreatitis unless there is infected necrosis.↗
▶Ep 1 · 33:08
clinicalWhen antibiotics are indicated for infected pancreatic necrosis, imipenem or 3rd generation cephalosporins are good initial choices.↗
▶Ep 1 · 34:34
guidelineThe INSPPIRE consortium defines acute recurrent pancreatitis in children as at least two distinct episodes with complete resolution of pain and a one-month pain-free interval, or normalization of enzymes with complete pain resolution in less than one month.↗
▶Ep 1 · 35:31
clinicalWorkup for acute recurrent pancreatitis includes inflammatory causes (IBD, celiac), systemic illnesses, mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing for PRSS1, SPINK1, CFTR, and CTRC.↗
▶Ep 1 · 43:35
epidemiologicalIn a prospective acute pancreatitis registry at Cincinnati Children's (nearly 3 years old), increased weight percentile-for-age (not BMI) during the first attack predicts recurrence.↗
▶Ep 1 · 43:58
epidemiologicalHigher BMI may predict severe pancreatitis course in adults and children based on studies outside the US, though this has not yet been proven in the Cincinnati US population (sample size 85 patients).↗
Acute Pancreatitis
▶Ep 6 · 2:40
clinicalAmylase rises and normalizes much quicker than lipase; in a patient presenting 2 days after symptom onset, amylase may not be the best indicator.↗
▶Ep 6 · 3:02
quotelipase half-life is about 7 days, but it's also more specific because it's mostly elevated if there's intestinal or pancreatic things. MLAse could be due to appendicitis.↗
▶Ep 6 · 3:02
clinicalLipase half-life is about 7 days and is more specific for pancreatic/intestinal pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary issues.↗
▶Ep 6 · 4:03
quoteThe ultrasound is really, that's the most helpful use of it. It's not really to document that the patient has pancreatitis or looking for complications. It's really looking if there's a biliary component.↗
▶Ep 6 · 4:03
clinicalThe most helpful use of ultrasound in acute pancreatitis is looking for a biliary component (CBD dilation suggesting early ERCP need, or gallstones changing management), not documenting pancreatitis or looking for complications.↗
▶Ep 6 · 5:00
clinicalCT is the imaging test of choice when complicated pancreatitis is suspected; it best visualizes necrosis, fluid collections, hemorrhage, and masses.↗
▶Ep 6 · 5:28
clinicalMRCP is useful for workup of biliary and pancreatic ductal issues but is not the first imaging modality in acute pancreatitis; edema during acute attack obscures ductal anatomy.↗
▶Ep 6 · 6:21
clinicalThere is no data on optimal pain medication in acute pancreatitis; even adult studies have not identified a superior medication.↗
▶Ep 6 · 6:27
opinionOpioids used in the right patient and setting in acute pancreatitis can allow earlier feeding, improve outcomes, and enable earlier discharge; providers should not be shy about using them.↗
▶Ep 6 · 6:27
quotedon't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier.↗
▶Ep 6 · 9:01
quoteThe data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate.↗
▶Ep 6 · 9:03
clinicalEarly enteral nutrition (within 24–72 hours) in acute pancreatitis is associated with more favorable outcomes: maintains gut barrier function, inhibits bacterial translocation, lowers incidence of systemic inflammatory response, and avoids severe complications.↗
▶Ep 6 · 9:32
host_summaryA 2012 meta-analysis comparing TPN vs. enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, surgical intervention rate, mortality, and infections.↗
▶Ep 6 · 12:41
host_summaryNG feeds vs. NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality are similar even in severe acute pancreatitis.↗
▶Ep 6 · 13:19
host_summaryThe 2007 Ekerwal study randomized 60 adult patients to eat on admission vs. NPO; early feeding did not increase abdominal pain and decreased length of stay by 2 days.↗
▶Ep 6 · 13:43
quoteGuess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not↗
▶Ep 6 · 14:29
clinicalCincinnati Children's replicated the early feeding approach in 38 pediatric admissions with mild pancreatitis (published late 2015); early nutrition was safe, feasible, and not associated with worse pain outcomes.↗
▶Ep 6 · 14:47
quoteThe patients who received feeds and the patients who were NPO had similar pain scores. These are patients who were evaluated multiple times per day, almost every 4 hours, subjectively and objectively by pain scores↗
▶Ep 6 · 15:28
clinicalPilot analysis showed patients who ate the most fat had the lowest pain scores; fat intake did not increase length of stay. Patients likely self-regulate and eat more when ready.↗
▶Ep 6 · 15:40
quoteThe lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat.↗
▶Ep 6 · 15:54
quoteIt's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home.↗
▶Ep 6 · 18:58
host_summaryAggressive IV fluid resuscitation in acute pancreatitis is associated with improved outcomes; early aggressive resuscitation (>1/3 of 72-hour fluid volume in first 24 hours) reduces mortality and incidence of SIRS and organ failure at 72 hours.↗
▶Ep 6 · 19:45
clinicalIn the late resuscitation group, patients received more total fluid than the early resuscitation group, but outcomes were worse, indicating a critical 24-hour window for intervention.↗
▶Ep 6 · 19:45
quoteyou've got a window and it's a 24 hours and if you don't interject then probably you lost your window↗
▶Ep 6 · 20:05
host_summaryA small 2011 study (40 patients) and a 2023 abstract (40 patients, Spain) showed early resuscitation with lactated Ringer's (LR) vs. normal saline reduced inflammation (CRP markers) when using goal-directed management targeting urine output 3 mL/kg/hr.↗
▶Ep 6 · 23:29
quotethe evidence shows that the outcomes are better with aggressive resuscitation.↗
▶Ep 6 · 24:10
clinicalCincinnati Children's study of 201 patients showed 35% of NPO + low IV fluids group developed severe pancreatitis vs. 4.2% in early PO + aggressive resuscitation group.↗
▶Ep 6 · 30:31
clinicalRanson's criteria applied to pediatric pancreatitis (studied since 2002, including Midwest/University of Cincinnati studies) initially showed promise but did not prove sufficiently sensitive and specific upon validation.↗
▶Ep 6 · 31:20
clinicalCincinnati Children's study proposes using white blood cell count, albumin, and lipase on admission to predict severity in ~70% of pediatric pancreatitis patients; this tool still needs optimization.↗
▶Ep 6 · 32:32
clinicalAntibiotics should not be used in mild pancreatitis or in severe pancreatitis unless infected necrosis is suspected (e.g., fever present).↗
▶Ep 6 · 33:08
clinicalWhen antibiotics are indicated in pancreatitis, imipenem or 3rd-generation cephalosporins are good initial choices based on available evidence.↗
▶Ep 6 · 34:47
host_summaryAcute recurrent pancreatitis (ARP) is defined by the INSPPIRE group as ≥2 distinct episodes with complete pain resolution and a 1-month pain-free interval, or enzyme normalization with complete pain resolution in <1 month.↗
clinicalCincinnati Children's prospective acute pancreatitis registry (3 years, 85 patients) found increased weight percentile for age (not BMI) during first attack predicts recurrence; abstract submitted to World Congress.↗
▶Ep 6 · 43:58
clinicalHigher BMI predicts severe pancreatitis course in adults and some pediatric studies outside the US, but did not predict severity in Cincinnati's 85-patient sample, possibly due to wide BMI variation in both recurrence and non-recurrence groups.↗
clinicalAmylase rises and normalizes much quicker than lipase; in a patient presenting 2 days after symptom onset, amylase may not be the best indicator.↗
▶Ep 7 · 3:02
clinicalLipase half-life is about 7 days and is more specific for pancreatic/intestinal pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary issues.↗
▶Ep 7 · 3:02
quotelipase half-life is about 7 days, but it's also more specific because it's mostly elevated if there's intestinal or pancreatic things. MLAse could be due to appendicitis.↗
▶Ep 7 · 4:03
quoteThe ultrasound is really, that's the most helpful use of it. It's not really to document that the patient has pancreatitis or looking for complications. It's really looking if there's a biliary component.↗
▶Ep 7 · 4:03
clinicalThe most helpful use of ultrasound in acute pancreatitis is looking for a biliary component (CBD dilation suggesting early ERCP need, or gallstones changing management), not documenting pancreatitis or looking for complications.↗
▶Ep 7 · 5:00
clinicalCT is the imaging test of choice when complicated pancreatitis is suspected; it best visualizes necrosis, fluid collections, hemorrhage, and masses.↗
▶Ep 7 · 5:28
clinicalMRCP is useful for workup of biliary and pancreatic ductal issues but is not the first imaging modality in acute pancreatitis; edema during acute attack obscures ductal anatomy.↗
▶Ep 7 · 6:21
clinicalThere is no data on optimal pain medication in acute pancreatitis; even adult studies have not identified a superior medication.↗
▶Ep 7 · 6:27
quotedon't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier.↗
▶Ep 7 · 6:27
opinionOpioids used in the right patient and setting in acute pancreatitis can allow earlier feeding, improve outcomes, and enable earlier discharge; providers should not be shy about using them.↗
▶Ep 7 · 9:01
quoteThe data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate.↗
▶Ep 7 · 9:03
clinicalEarly enteral nutrition (within 24–72 hours) in acute pancreatitis is associated with more favorable outcomes: maintains gut barrier function, inhibits bacterial translocation, lowers incidence of systemic inflammatory response, and avoids severe complications.↗
▶Ep 7 · 9:32
host_summaryA 2012 meta-analysis comparing TPN vs. enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, surgical intervention rate, mortality, and infections.↗
▶Ep 7 · 12:41
host_summaryNG feeds vs. NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality are similar even in severe acute pancreatitis.↗
▶Ep 7 · 13:19
host_summaryThe 2007 Ekerwal study randomized 60 adult patients to eat on admission vs. NPO; early feeding did not increase abdominal pain and decreased length of stay by 2 days.↗
▶Ep 7 · 13:43
quoteGuess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not↗
▶Ep 7 · 14:29
clinicalCincinnati Children's replicated the early feeding approach in 38 pediatric admissions with mild pancreatitis (published late 2015); early nutrition was safe, feasible, and not associated with worse pain outcomes.↗
▶Ep 7 · 14:47
quoteThe patients who received feeds and the patients who were NPO had similar pain scores. These are patients who were evaluated multiple times per day, almost every 4 hours, subjectively and objectively by pain scores↗
▶Ep 7 · 15:28
clinicalPilot analysis showed patients who ate the most fat had the lowest pain scores; fat intake did not increase length of stay. Patients likely self-regulate and eat more when ready.↗
▶Ep 7 · 15:40
quoteThe lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat.↗
▶Ep 7 · 15:54
quoteIt's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home.↗
▶Ep 7 · 18:58
host_summaryAggressive IV fluid resuscitation in acute pancreatitis is associated with improved outcomes; early aggressive resuscitation (>1/3 of 72-hour fluid volume in first 24 hours) reduces mortality and incidence of SIRS and organ failure at 72 hours.↗
▶Ep 7 · 19:45
clinicalIn the late resuscitation group, patients received more total fluid than the early resuscitation group, but outcomes were worse, indicating a critical 24-hour window for intervention.↗
▶Ep 7 · 19:45
quoteyou've got a window and it's a 24 hours and if you don't interject then probably you lost your window↗
▶Ep 7 · 20:05
host_summaryA small 2011 study (40 patients) and a 2023 abstract (40 patients, Spain) showed early resuscitation with lactated Ringer's (LR) vs. normal saline reduced inflammation (CRP markers) when using goal-directed management targeting urine output 3 mL/kg/hr.↗
▶Ep 7 · 23:29
quotethe evidence shows that the outcomes are better with aggressive resuscitation.↗
▶Ep 7 · 24:10
clinicalCincinnati Children's study of 201 patients showed 35% of NPO + low IV fluids group developed severe pancreatitis vs. 4.2% in early PO + aggressive resuscitation group.↗
▶Ep 7 · 30:31
clinicalRanson's criteria applied to pediatric pancreatitis (studied since 2002, including Midwest/University of Cincinnati studies) initially showed promise but did not prove sufficiently sensitive and specific upon validation.↗
▶Ep 7 · 31:20
clinicalCincinnati Children's study proposes using white blood cell count, albumin, and lipase on admission to predict severity in ~70% of pediatric pancreatitis patients; this tool still needs optimization.↗
▶Ep 7 · 32:32
clinicalAntibiotics should not be used in mild pancreatitis or in severe pancreatitis unless infected necrosis is suspected (e.g., fever present).↗
▶Ep 7 · 33:08
clinicalWhen antibiotics are indicated in pancreatitis, imipenem or 3rd-generation cephalosporins are good initial choices based on available evidence.↗
▶Ep 7 · 34:47
host_summaryAcute recurrent pancreatitis (ARP) is defined by the INSPPIRE group as ≥2 distinct episodes with complete pain resolution and a 1-month pain-free interval, or enzyme normalization with complete pain resolution in <1 month.↗
clinicalCincinnati Children's prospective acute pancreatitis registry (3 years, 85 patients) found increased weight percentile for age (not BMI) during first attack predicts recurrence; abstract submitted to World Congress.↗
▶Ep 7 · 43:58
clinicalHigher BMI predicts severe pancreatitis course in adults and some pediatric studies outside the US, but did not predict severity in Cincinnati's 85-patient sample, possibly due to wide BMI variation in both recurrence and non-recurrence groups.↗
quoteDoes he meet criteria for acute pancreatitis and based on what I showed you, We think he does↗
▶Ep 12 · 2:23
clinicalUltrasound is limited in the setting of suspected complications of pancreatitis; CT is the image of choice for complicated cases to better visualize necrosis, fluid collections, hemorrhage, or masses.↗
▶Ep 12 · 2:40
clinicalAmylase rises and normalizes much quicker than lipase, so in a patient presenting 2 days after symptom onset, amylase may not be the best indicator of pancreatitis.↗
▶Ep 12 · 2:40
quoteSo it's not that the sensitivity is different early on, but amylase rises and normalizes much quicker than the lipase.↗
▶Ep 12 · 3:00
clinicalLipase half-life is about 7 days and is more specific for pancreatic pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary disease.↗
▶Ep 12 · 4:03
clinicalThe most helpful use of ultrasound in acute pancreatitis is looking for a biliary component—CBD dilation suggesting need for early ERCP, or gallstones that change management—not documenting pancreatitis or looking for complications.↗
▶Ep 12 · 5:15
clinicalMRCP is not the most helpful imaging modality during an acute pancreatitis attack because edema obscures ductal anatomy; it is better reserved for workup of biliary and pancreatic ductal issues after resolution.↗
▶Ep 12 · 6:21
clinicalThere is no data identifying a superior pain medication for acute pancreatitis; even adult studies have not identified optimal management.↗
▶Ep 12 · 6:27
quotedon't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier.↗
▶Ep 12 · 6:35
clinicalOpioids should not be avoided in acute pancreatitis; when used appropriately, they can help advance feeds, improve outcomes, and facilitate earlier discharge.↗
▶Ep 12 · 9:01
quoteThe data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate.↗
▶Ep 12 · 9:03
clinicalEarly nutrition (within 24 to 72 hours) in acute pancreatitis is associated with more favorable outcomes: it maintains gut barrier function, inhibits bacterial translocation, and lowers the incidence of systemic inflammatory response.↗
▶Ep 12 · 9:32
epidemiologicalA 2012 meta-analysis comparing TPN versus enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, reduced surgical intervention rate, lower mortality, and fewer infections.↗
▶Ep 12 · 12:41
epidemiologicalStudies comparing NG feeds versus NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality were very similar, even in severe acute pancreatitis.↗
▶Ep 12 · 13:19
epidemiologicalThe Ekerwal 2007 study randomized 60 adult patients to eat on admission versus NPO and found that early feeding did not increase abdominal pain and decreased length of stay by 2 days.↗
▶Ep 12 · 13:43
quoteGuess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not↗
▶Ep 12 · 14:29
epidemiologicalIn a Cincinnati Children's study of 38 admissions for mild pancreatitis, early nutrition was safe and feasible, and patients who received feeds had similar pain scores to those kept NPO.↗
▶Ep 12 · 15:25
quoteI haven't found a good evidence for the low fat. However, we know that fat stimulates lipase and we don't want to increase lipase.↗
▶Ep 12 · 15:28
epidemiologicalPilot analysis showed patients with the lowest pain scores were those who ate the most fat; fat intake did not increase length of stay.↗
▶Ep 12 · 15:40
quoteThe lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat.↗
▶Ep 12 · 15:54
quoteIt's, it's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home.↗
▶Ep 12 · 19:02
epidemiologicalAggressive IV fluid resuscitation (more than one-third of 72-hour fluid volume given in the first day) is associated with reduced mortality and reduced incidence of SIRS and organ failure at 72 hours.↗
▶Ep 12 · 19:45
clinicalIn studies of aggressive resuscitation, the late resuscitation group received more total fluid than the early resuscitation group, suggesting a critical 24-hour window for intervention.↗
▶Ep 12 · 19:45
quotereally you've got a window and it's a 24 hours and if you don't interject then probably you lost your window↗
▶Ep 12 · 20:18
epidemiologicalA 2011 study of 40 patients using goal-directed management (resuscitating to urine output of 3 mL/kg/hour) showed early resuscitation with lactated Ringer's reduced inflammation markers (CRP) compared to normal saline.↗
▶Ep 12 · 20:48
quoteAnd here brings the question of should we all use LR? Again, this is one study.↗
▶Ep 12 · 22:13
quotewhen we aggressively resuscitate, there are some evidence that shows that you could actually flood the lungs and result in pulmonary edema↗
▶Ep 12 · 23:48
epidemiologicalIn a Cincinnati Children's study of 201 patients, those kept NPO with low IV fluids had 35% rate of developing severe pancreatitis, versus 4.2% in those who ate early and received aggressive resuscitation.↗
▶Ep 12 · 24:50
quoteThe classic story, since we're talking about diseased pancreas, it can't be that easy, right?↗
▶Ep 12 · 25:21
quotewhen the patients are not NPO enough time and I don't know, Andrew, if you want to comment why sometimes we get the non-specific findings or not adequate to comment↗
▶Ep 12 · 30:31
clinicalRanson's criteria have not proven sensitive and specific for predicting severity in pediatric pancreatitis when validated in further studies, despite initial promise in a 2002 Midwest study.↗
▶Ep 12 · 31:20
epidemiologicalA Cincinnati Children's prognostic tool using white blood cell count, albumin value, and lipase on admission can predict severity in almost 70% of pediatric pancreatitis patients.↗
▶Ep 12 · 32:32
clinicalAntibiotics should not be used routinely in mild acute pancreatitis or in severe pancreatitis unless there is infected necrosis.↗
▶Ep 12 · 33:08
clinicalWhen antibiotics are indicated for infected pancreatic necrosis, imipenem or 3rd generation cephalosporins are good initial choices.↗
▶Ep 12 · 34:34
guidelineThe INSPPIRE consortium defines acute recurrent pancreatitis in children as at least two distinct episodes with complete resolution of pain and a one-month pain-free interval, or normalization of enzymes with complete pain resolution in less than one month.↗
▶Ep 12 · 35:31
clinicalWorkup for acute recurrent pancreatitis includes inflammatory causes (IBD, celiac), systemic illnesses, mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing for PRSS1, SPINK1, CFTR, and CTRC.↗
▶Ep 12 · 43:35
epidemiologicalIn a prospective acute pancreatitis registry at Cincinnati Children's (nearly 3 years old), increased weight percentile-for-age (not BMI) during the first attack predicts recurrence.↗
▶Ep 12 · 43:58
epidemiologicalHigher BMI may predict severe pancreatitis course in adults and children based on studies outside the US, though this has not yet been proven in the Cincinnati US population (sample size 85 patients).↗
quoteDoes he meet criteria for acute pancreatitis and based on what I showed you, We think he does↗
▶Ep 2 · 2:23
clinicalUltrasound is limited in the setting of suspected complications of pancreatitis; CT is the image of choice for complicated cases to better visualize necrosis, fluid collections, hemorrhage, or masses.↗
▶Ep 2 · 2:40
clinicalAmylase rises and normalizes much quicker than lipase, so in a patient presenting 2 days after symptom onset, amylase may not be the best indicator of pancreatitis.↗
▶Ep 2 · 2:40
quoteSo it's not that the sensitivity is different early on, but amylase rises and normalizes much quicker than the lipase.↗
▶Ep 2 · 3:00
clinicalLipase half-life is about 7 days and is more specific for pancreatic pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary disease.↗
▶Ep 2 · 4:03
clinicalThe most helpful use of ultrasound in acute pancreatitis is looking for a biliary component—CBD dilation suggesting need for early ERCP, or gallstones that change management—not documenting pancreatitis or looking for complications.↗
▶Ep 2 · 5:15
clinicalMRCP is not the most helpful imaging modality during an acute pancreatitis attack because edema obscures ductal anatomy; it is better reserved for workup of biliary and pancreatic ductal issues after resolution.↗
▶Ep 2 · 6:21
clinicalThere is no data identifying a superior pain medication for acute pancreatitis; even adult studies have not identified optimal management.↗
▶Ep 2 · 6:27
quotedon't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier.↗
▶Ep 2 · 6:35
clinicalOpioids should not be avoided in acute pancreatitis; when used appropriately, they can help advance feeds, improve outcomes, and facilitate earlier discharge.↗
▶Ep 2 · 9:01
quoteThe data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate.↗
▶Ep 2 · 9:03
clinicalEarly nutrition (within 24 to 72 hours) in acute pancreatitis is associated with more favorable outcomes: it maintains gut barrier function, inhibits bacterial translocation, and lowers the incidence of systemic inflammatory response.↗
▶Ep 2 · 9:32
epidemiologicalA 2012 meta-analysis comparing TPN versus enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, reduced surgical intervention rate, lower mortality, and fewer infections.↗
▶Ep 2 · 12:41
epidemiologicalStudies comparing NG feeds versus NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality were very similar, even in severe acute pancreatitis.↗
▶Ep 2 · 13:19
epidemiologicalThe Ekerwal 2007 study randomized 60 adult patients to eat on admission versus NPO and found that early feeding did not increase abdominal pain and decreased length of stay by 2 days.↗
▶Ep 2 · 13:43
quoteGuess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not↗
▶Ep 2 · 14:29
epidemiologicalIn a Cincinnati Children's study of 38 admissions for mild pancreatitis, early nutrition was safe and feasible, and patients who received feeds had similar pain scores to those kept NPO.↗
▶Ep 2 · 15:25
quoteI haven't found a good evidence for the low fat. However, we know that fat stimulates lipase and we don't want to increase lipase.↗
▶Ep 2 · 15:28
epidemiologicalPilot analysis showed patients with the lowest pain scores were those who ate the most fat; fat intake did not increase length of stay.↗
▶Ep 2 · 15:40
quoteThe lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat.↗
▶Ep 2 · 15:54
quoteIt's, it's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home.↗
▶Ep 2 · 19:02
epidemiologicalAggressive IV fluid resuscitation (more than one-third of 72-hour fluid volume given in the first day) is associated with reduced mortality and reduced incidence of SIRS and organ failure at 72 hours.↗
▶Ep 2 · 19:45
clinicalIn studies of aggressive resuscitation, the late resuscitation group received more total fluid than the early resuscitation group, suggesting a critical 24-hour window for intervention.↗
▶Ep 2 · 19:45
quotereally you've got a window and it's a 24 hours and if you don't interject then probably you lost your window↗
▶Ep 2 · 20:18
epidemiologicalA 2011 study of 40 patients using goal-directed management (resuscitating to urine output of 3 mL/kg/hour) showed early resuscitation with lactated Ringer's reduced inflammation markers (CRP) compared to normal saline.↗
▶Ep 2 · 20:48
quoteAnd here brings the question of should we all use LR? Again, this is one study.↗
▶Ep 2 · 22:13
quotewhen we aggressively resuscitate, there are some evidence that shows that you could actually flood the lungs and result in pulmonary edema↗
▶Ep 2 · 23:48
epidemiologicalIn a Cincinnati Children's study of 201 patients, those kept NPO with low IV fluids had 35% rate of developing severe pancreatitis, versus 4.2% in those who ate early and received aggressive resuscitation.↗
▶Ep 2 · 24:50
quoteThe classic story, since we're talking about diseased pancreas, it can't be that easy, right?↗
▶Ep 2 · 25:21
quotewhen the patients are not NPO enough time and I don't know, Andrew, if you want to comment why sometimes we get the non-specific findings or not adequate to comment↗
▶Ep 2 · 30:31
clinicalRanson's criteria have not proven sensitive and specific for predicting severity in pediatric pancreatitis when validated in further studies, despite initial promise in a 2002 Midwest study.↗
▶Ep 2 · 31:20
epidemiologicalA Cincinnati Children's prognostic tool using white blood cell count, albumin value, and lipase on admission can predict severity in almost 70% of pediatric pancreatitis patients.↗
▶Ep 2 · 32:32
clinicalAntibiotics should not be used routinely in mild acute pancreatitis or in severe pancreatitis unless there is infected necrosis.↗
▶Ep 2 · 33:08
clinicalWhen antibiotics are indicated for infected pancreatic necrosis, imipenem or 3rd generation cephalosporins are good initial choices.↗
▶Ep 2 · 34:34
guidelineThe INSPPIRE consortium defines acute recurrent pancreatitis in children as at least two distinct episodes with complete resolution of pain and a one-month pain-free interval, or normalization of enzymes with complete pain resolution in less than one month.↗
▶Ep 2 · 35:31
clinicalWorkup for acute recurrent pancreatitis includes inflammatory causes (IBD, celiac), systemic illnesses, mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing for PRSS1, SPINK1, CFTR, and CTRC.↗
▶Ep 2 · 43:35
epidemiologicalIn a prospective acute pancreatitis registry at Cincinnati Children's (nearly 3 years old), increased weight percentile-for-age (not BMI) during the first attack predicts recurrence.↗
▶Ep 2 · 43:58
epidemiologicalHigher BMI may predict severe pancreatitis course in adults and children based on studies outside the US, though this has not yet been proven in the Cincinnati US population (sample size 85 patients).↗
Acute Pancreatitis
▶Ep 12 · 2:40
clinicalAmylase rises and normalizes much quicker than lipase; in a patient presenting 2 days after symptom onset, amylase may not be the best indicator.↗
▶Ep 12 · 3:02
quotelipase half-life is about 7 days, but it's also more specific because it's mostly elevated if there's intestinal or pancreatic things. MLAse could be due to appendicitis.↗
▶Ep 12 · 3:02
clinicalLipase half-life is about 7 days and is more specific for pancreatic/intestinal pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary issues.↗
▶Ep 12 · 4:03
quoteThe ultrasound is really, that's the most helpful use of it. It's not really to document that the patient has pancreatitis or looking for complications. It's really looking if there's a biliary component.↗
▶Ep 12 · 4:03
clinicalThe most helpful use of ultrasound in acute pancreatitis is looking for a biliary component (CBD dilation suggesting early ERCP need, or gallstones changing management), not documenting pancreatitis or looking for complications.↗
▶Ep 12 · 5:00
clinicalCT is the imaging test of choice when complicated pancreatitis is suspected; it best visualizes necrosis, fluid collections, hemorrhage, and masses.↗
▶Ep 12 · 5:28
clinicalMRCP is useful for workup of biliary and pancreatic ductal issues but is not the first imaging modality in acute pancreatitis; edema during acute attack obscures ductal anatomy.↗
▶Ep 12 · 6:21
clinicalThere is no data on optimal pain medication in acute pancreatitis; even adult studies have not identified a superior medication.↗
▶Ep 12 · 6:27
opinionOpioids used in the right patient and setting in acute pancreatitis can allow earlier feeding, improve outcomes, and enable earlier discharge; providers should not be shy about using them.↗
▶Ep 12 · 6:27
quotedon't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier.↗
▶Ep 12 · 9:01
quoteThe data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate.↗
▶Ep 12 · 9:03
clinicalEarly enteral nutrition (within 24–72 hours) in acute pancreatitis is associated with more favorable outcomes: maintains gut barrier function, inhibits bacterial translocation, lowers incidence of systemic inflammatory response, and avoids severe complications.↗
▶Ep 12 · 9:32
host_summaryA 2012 meta-analysis comparing TPN vs. enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, surgical intervention rate, mortality, and infections.↗
▶Ep 12 · 12:41
host_summaryNG feeds vs. NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality are similar even in severe acute pancreatitis.↗
▶Ep 12 · 13:19
host_summaryThe 2007 Ekerwal study randomized 60 adult patients to eat on admission vs. NPO; early feeding did not increase abdominal pain and decreased length of stay by 2 days.↗
▶Ep 12 · 13:43
quoteGuess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not↗
▶Ep 12 · 14:29
clinicalCincinnati Children's replicated the early feeding approach in 38 pediatric admissions with mild pancreatitis (published late 2015); early nutrition was safe, feasible, and not associated with worse pain outcomes.↗
▶Ep 12 · 14:47
quoteThe patients who received feeds and the patients who were NPO had similar pain scores. These are patients who were evaluated multiple times per day, almost every 4 hours, subjectively and objectively by pain scores↗
▶Ep 12 · 15:28
clinicalPilot analysis showed patients who ate the most fat had the lowest pain scores; fat intake did not increase length of stay. Patients likely self-regulate and eat more when ready.↗
▶Ep 12 · 15:40
quoteThe lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat.↗
▶Ep 12 · 15:54
quoteIt's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home.↗
▶Ep 12 · 18:58
host_summaryAggressive IV fluid resuscitation in acute pancreatitis is associated with improved outcomes; early aggressive resuscitation (>1/3 of 72-hour fluid volume in first 24 hours) reduces mortality and incidence of SIRS and organ failure at 72 hours.↗
▶Ep 12 · 19:45
clinicalIn the late resuscitation group, patients received more total fluid than the early resuscitation group, but outcomes were worse, indicating a critical 24-hour window for intervention.↗
▶Ep 12 · 19:45
quoteyou've got a window and it's a 24 hours and if you don't interject then probably you lost your window↗
▶Ep 12 · 20:05
host_summaryA small 2011 study (40 patients) and a 2023 abstract (40 patients, Spain) showed early resuscitation with lactated Ringer's (LR) vs. normal saline reduced inflammation (CRP markers) when using goal-directed management targeting urine output 3 mL/kg/hr.↗
▶Ep 12 · 23:29
quotethe evidence shows that the outcomes are better with aggressive resuscitation.↗
▶Ep 12 · 24:10
clinicalCincinnati Children's study of 201 patients showed 35% of NPO + low IV fluids group developed severe pancreatitis vs. 4.2% in early PO + aggressive resuscitation group.↗
▶Ep 12 · 30:31
clinicalRanson's criteria applied to pediatric pancreatitis (studied since 2002, including Midwest/University of Cincinnati studies) initially showed promise but did not prove sufficiently sensitive and specific upon validation.↗
▶Ep 12 · 31:20
clinicalCincinnati Children's study proposes using white blood cell count, albumin, and lipase on admission to predict severity in ~70% of pediatric pancreatitis patients; this tool still needs optimization.↗
▶Ep 12 · 32:32
clinicalAntibiotics should not be used in mild pancreatitis or in severe pancreatitis unless infected necrosis is suspected (e.g., fever present).↗
▶Ep 12 · 33:08
clinicalWhen antibiotics are indicated in pancreatitis, imipenem or 3rd-generation cephalosporins are good initial choices based on available evidence.↗
▶Ep 12 · 34:47
host_summaryAcute recurrent pancreatitis (ARP) is defined by the INSPPIRE group as ≥2 distinct episodes with complete pain resolution and a 1-month pain-free interval, or enzyme normalization with complete pain resolution in <1 month.↗
clinicalCincinnati Children's prospective acute pancreatitis registry (3 years, 85 patients) found increased weight percentile for age (not BMI) during first attack predicts recurrence; abstract submitted to World Congress.↗
▶Ep 12 · 43:58
clinicalHigher BMI predicts severe pancreatitis course in adults and some pediatric studies outside the US, but did not predict severity in Cincinnati's 85-patient sample, possibly due to wide BMI variation in both recurrence and non-recurrence groups.↗
