Acute Pancreatitis

While most of these audio chapters are recordings between myself and experts in the field, we wanted to try something new this time. Acute pancreatitis is a common problem we have to deal with in pediatric surgery, and I had the pleasure of hearing one of the best lectures on this topic by Doctor Maissam Abu Al Haija at Cincinnati Children's Hospital. She highlighted all of the new ideas that are coming out in acute pancreatitis, and I thought this would be a great podcast for stay current. This is actually taken from a previous global cast. In this recording, you'll hear from other experts like Dr. Jamie Nathan, Dr. Tom Lynn, and Dr. Andrew Trout, all from the Pancreas Care Center at Cincinnati Children's Hospital. We hope you enjoy. Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Ian Glenn, Sophia Abdulhai, and Abdul Roof Lamoshi and is recorded and produced at Akron Children's Hospital in Akron, Ohio. So I'll start by a case and to show you a real case from our practice when a 9-year-old comes to the emergency department because he has this sharp, intense belly pain, he rated it 7 out of 10. It started kind of 2 days before coming, and he also has vomiting, and I showed the labs, so the amylase was 100. Our upper limit of normal in this institution is 109, and the lipase was 9800. And the upper limit is about 199 or 200, so Does he meet criteria for acute pancreatitis and based on what I showed you, We think he does, but moreover, we did get an ultrasound, and I'll let Dr. Andrew Trout comment on what we saw in his ultrasound at that time. And we like to use ultrasound as our initial imaging test in children where there's suspected uncomplicated acute pancreatitis, and the value of ultrasound is that it is a radiation-free modality. It gives you in general a reasonably good look at the pancreas. That said, it's a little bit limited in the setting where you are concerned about. Complications of pancreatitis. Yes, can I ask a question? And by the way, absolutely tell me to shut up if I'm obstructing this conversation. Amylase and lipase, lipase more sensitive than amylase? Yes, that's a great question. So it's not that the sensitivity is different early on, but amylase rises and normalizes much quicker than the lipase. So if you remember with the case, the kid presented two days prior. Having symptoms for almost 2 days. So that's what we commonly see. The MLAs might not be your best indicator. Got it. Um, lipase is more specific though. So lipase 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. I mean, as a surgeon, you probably know that. GYN things could cause that salivary, so amylase is less specific for the pancreas, but I think this is classically what we see. Some people get a little bit confused. They're like, Well, your amylase is not elevated. You probably don't have pancreatitis, and we, knowing what I just presented, yes, it's classic really for pancreatitis. Got it. And then for you, you obviously usually would go over to gallbladder. Make sure there's no stones and evaluate the duct and all that stuff. Correct? Yes, this was just a selected image from an exam because of what we're covering today for sure though, you want to rule out potential causes of that pancreatitis, gallstones, and obviously we're looking for those complications. They're not going to be fully characterized by ultrasound. You may need to go to CT, but at least it gives us an initial look. If we see a lot of fluid, if we see, you know, areas that look like necrosis, then we may consider going on to another modality at that point. Got it. Thanks. Yeah, but thank you for that question, Todd, because the 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. So if there's CBD dilation, then you would consider an ERCP early, or if there's gallstones, then that changes the whole management. Got it. So further on with the history, you know, this kid has been healthy, no family history of any diseases, no medications, no trauma. He might have had some flu-like symptoms, really nothing too impressive. So low grade fever, sore throat, and myalgias. And I just want to cover in a couple of slides what is imaging in acute pancreatitis. Dr. Trout alluded to that earlier. Really, the ultrasound should be the initial imaging for the reasons he mentioned. It is used to confirm the diagnosis and also we screen for complications in identifying gallstones. CT is the image of choice if we're thinking about a complicated case. It is a much better modality to better visualize the necrosis and fluid collections, hemorrhage, or masses. MRCP, it's, it's a very useful imaging tool we'll be showing through the talk today, you know, through really the whole course, the uses of MRCP and different indications. What I would like to say is that we get calls often. So the kid has acute pancreatitis. Do you want an MRCP? That's really not the first imaging modality that I want to think about in the. acute attack event, the edema tends to obscure ductal anatomy, so it's not the most helpful if you're looking for ductal irregularities or even anatomic things, and we usually leave the MRCP for workup of these kind of biliary and pancreatic ductal issues. Talking about pain and we're very lucky that the way we managed even acute pancreatitis and Dr. Ken Goldschneider will elaborate more on management of chronic pancreatitis, which you know, the hallmark of the disease is pain. He helped us, like I will show later in the order set. Incorporate what is best management for acute pancreatitis, and we really built it based on the sparse evidence that we have available. So what I would like to highlight from this slide is that there is no data on what is optimal management. Even the studies in adults have not identified a superior medication in acute pancreatitis, and don'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. However, you know, we don't want to use too much because there are newer medications that could really help. What we call narcotics sparing or opioid sparing medications in pediatrics, and we really need more trials on those. So we're going to talk about the nuts and bolts of management, OK? You get a patient, what are you going to do? Are you going to feed them? Are you going to admit them? Are you going to send them home? What IV fluids? This is supposed to be open to discussion, so feel free to send your input and points as we're going through, but I'll start with a poll question. So for how long would you keep the patients with mild pancreatitis, and really the patient that I just presented is mild. It's mild because there was no evidence of pancreatic complications and because the kid did not have systemic inflammatory response syndromes or signs of multi-organ failure. So that's really the majority of pediatric pancreatitis. Would you keep them NPO for the 1st 11 to 3 days? Would you keep them NPO until their lipase and amylase normalize, so checking them every day until they're normalized? Would you keep them NPO until their pain is gone, or NPA until they're off narcotics? Or do you allow your patients to eat immediately and you don't keep them NPO? So let's see the responses and how people responded to the poll question. So I can tell you that right now it's about 30% mark. If you can pull up question one, topic one, question one. So it's divided three ways between NPO for the 1st 24 to 72 hours is where most people wrote, and that was before you gave your answer and then I allow my opinion, no, that's not the right one, Mark. Yes, that's not the right one. And then the other people were divided between. NPO until their pain is improved or gone, which was my answer. That's what I was, and, and so I already I've learned three things which I'm gonna tell you. And then, um, NPO until they're off narcotics was another, uh, common answer, right. So nutrition is very, very important, and actually the more we know about it, uh, the more I'm intrigued about how you should tailor specific nutrition therapies to mild pancreatitis versus severe pancreatitis. The 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. It is associated with more favorable outcomes, and it's all the reasons that I mentioned here. It helps maintain that gut barrier function, inhibits bacteria translocation. The gut is very inflamed and leaky at that time. It actually lowers the incidence of systemic inflammatory response, hence avoids having severe complications of pancreatitis. I will just show one meta analysis because this is the strongest level of evidence we could have. This was in 2012 where they compared TPN, so total parenteral nutrition versus enteral nutrition, in the predicted severe acute pancreatitis, and enteral really was associated with better outcomes in terms of decreased organ failure and surgical intervention rate. And these are forest plots. So it again shows that um the, for mortality, the analysis favored enteral nutrition and for infections, the analysis favored enteral nutrition. So very strong evidence from pooled analysis from different studies that if you have even the predicted severe, go ahead and allow nutrition. So can I ask you a question? So so far I've learned that I was always afraid of opioids, so that's something I don't need to be afraid of anymore. I thought it's going to cause, make the pancreas worse because the sphincter have already spasm. No good data is what I good data. It's really conflicting. That's an important key point to Yes, send out to the, OK. Second thing is, oh, and a new person just answered another one NPO until their lipase and amylase normalize, which is what I see a lot. I think the majority tends to do that, yes, yes, until pain is improved or lipase and amylase, so OK. In other words, they cooled down the pancreas. They cooled down. That's what I always thought, right? This is why this is so great for me. Everybody's afraid of aggravating the pancreas, right, right? That's right. So what about we keep getting new answers now. So what about how do you feed them? You said enteral nutrition. They're going to throw it right out. Yes. So what do you do? I think I'll show you in a second how we incorporated standardized. Every mild pancreatitis case gets the standard management. We made it easy on providers hospital-wide, you know, we are 659 beds or almost 700 beds with the expansion, so it was very, very important to standardize how we manage the cases. These patients are under HMO floors, trauma, and obviously that's a different case in some aspects because if the duct is not in continuity, then you probably can't feed them, but Cardiac kids, GI, general peds, so they go all over, and it was very important just to say allow the kids to eat. Yes, they're going to self-regulate and I'll show you the data in a second, OK, but that was the most easy one. We haven't gone to feed them aggressively now when you get into the severe. They're probably not going to be able to eat and that's where the art comes to use some internal nutrition mode to really expedite the healing without tipping things over, OK, and so you're going to show us this algorithm on how you, I'll show you some things from our electronic medical record of how we make it easy and provide. To order the standardized management, but this could be again orders on papers elsewhere. This could be used in any other electronic medical record that the other institutions used. I've shared it with a lot of other institutions and I found it very helpful. I would love it. Yeah, sure, you've got to pay money though. I know fair enough, fair enough. So we answered the poll question really the answers were within the realm of what people were doing before we standardized management three years ago, OK. Um, Again, um, to Todd's question, NG feed versus NJ feeds, really, the majority of the studies shows different, um, sorry, no difference, so same outcomes. The duration of hospital stay and mortality were very similar, and this is, for instance, one small randomized trial with even severe acute pancreatitis. NG and NJ similar outcomes. So if you can feed with NG, there's probably not much added benefit from inserting the NJ under floro, and sometimes these are difficult cases and going that route. This is the first in design, and that's why I show it. In 2007 was the concept when do not. Rest the pancreas came about and this is a study from Ekerwal and colleagues where they really just simple in design, randomized 60 adult patients, allowed 30 of them to eat on admission, and kept 30 of them NPO on admission and really the NPO was the classic method they managed the patient. 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, and that's what the study showed. And then the main outcome actually that they showed a difference, which is a big thing for hospitals right now, especially with the healthcare reform and everything that we're going through in this era, they decreased the length of stay by 2 days in the group that ate earlier, so that was very, very beneficial. If I show that to my hospital, they would love me too, and everybody who hears us, I'm sure patients would love it. It's a very important patient related outcome. So 2 days earlier discharged in the group that 8, same pain um scores in both groups. So, and no harmful events. So we replicated that in kids and this was just published actually late in 2015. I just allowed the kids to eat like I mentioned and 38 admissions, mild pancreatitis. We have shown that we could do that in kids, that early nutrition is safe, feasible, and is not associated with pain outcomes. In fact, The 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, and they really had similar scoring assessment. And then we really wanted to look at whether fat intake, so we start the patient on feeds, we say low fat diet. Again, that's another thing that Has been planted in our heads and I've been looking on the evidence and if anybody from the audience has a great point on that, please fill in to call or send us your thoughts. I 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. But at least from this pilot analysis that we did, we showed that the ones who had, um, so if I want to show here. The lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat. I just don't get that. It's a myth. It's a surprise, but it actually decreases pain. It'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. Um, does fat intake increase the length of stay? Um, so we looked at the total hospital stay and really it didn't affect the length of stay. Um, I think we probably talked enough from a nutrition standpoint. I don't know if there are questions we need to cover, but from there I would jump to the IV fluids, which is again a very important aspect from the moment the patient hits the ER, what are you gonna do? And we know that sometimes our surgical colleagues love the LR and GI colleagues love the normal saline, and that's another debate too. Before we jump to IV fluids, there was a comment from the audience regarding emesis. Patient presents with emesis and pancreatitis. You know, I think we need to be clear that, you know, we're not force feeding the kids. Exactly. We're not pushing feeds in the face of ongoing emesis. I agree. I agree. So again with our pain order sets that Dr. Goldschneider helped us build, we have. Narcotics pairing medications and I probably should change the name, right? I should say opioids pairing. OK, so we use IV Tylenol, we use ibuprofen, we use things that allow the gut to move better, so do not delay gastric emptying and things, and pancreatitis itself could cause ileus, so those medications help not have ileus, but we also keep them comfortable with Zofran and things like that, so. All right. Another poll question is coming. So, what would you choose as the IV fluid of choice for administration um when you start the patients with acute pancreatitis, um, on any IV fluids? Would you not use IV fluids? Would you have normal saline bolus followed by 1 time maintenance D5NS? Would you have normal saline bolus followed by 1 time maintenance LR? Would you have normal saline bolus followed by You know, kind of higher than maintenance, so more than 1.5 maintenance of D5NS or bolus followed by more than 1.5 LR. See the poll question responses on that. Yeah, so, um, can you pull up topic one question two. Almost 60% said the normal sailing bowls followed by 1.5 times maintenance of LR. Um, the other two responses were normal saline followed by one half maintenance of D5 normal saline and um. By let's see, this one is 11 times maintenance of LR. So, but it looks like the majority are saying 1.5 LR. I, I agree. So the majority is aware of the evidence of aggressive resuscitation. That's really great, and I think the LR remains. Kind of debatable. I know that there are centers that strictly shifted to LR versus we, for instance, have not shifted yet because there's no studies in pediatrics, um, but it's a very intriguing concept to be studied further. But we all agree on the aggressive resuscitation. So the adult studies showed that aggressive resuscitation is associated with improved outcomes, and these are retrospective studies, but they really defined the early aggressive as they calculated what is the 72 hour fluid volume for a patient, and if the patient got more than a third of that in the first day, it was counted as aggressive. Two studies at least showed beneficial event. Benefits, so it was associated with reduced mortality and the early fluid resuscitation was associated with reduced incidence of SIRS and organ failure at 72 hours. Here I show the graph that shows the SURS and organ failure decreased at 72 hours in the group that got aggressive resuscitation. By the way, in the late resuscitation group in total they got more than what the earlier resuscitation group got. So that puts the pressure that really you've got a window and it's a 24 hours and if you don't interject then probably you lost your window and more than 85% of patients really got normal saline. And then another small study showed the benefits of LR and actually there is another one that was presented at DDW this year that again showed. Benefits of LR. Again, this study is 40 patients from 2011. The abstract from Spain this year, I believe it was from Spain, was 40 patients. So they used LR versus normal saline, and they used a goal-directed management where they aggressively resuscitated until the urine output was at 3 mL per kilo per hour. Um, and the results showed that early resuscitation with LR did lead to reduced inflammation with certain CRP markers compared to normal saline. So both groups got the same rate. One got LR and one got NS. And here brings the question of should we all use LR? Again, this is one study. So let's, so I'm just going to show you snapshots of our order set. Do you get the surgeons involved early in these patients? Are these usually managed by you guys and then you call them if there's a problem. I think Dr. Lin has a very good experience on the gallstone pancreatitis, and mostly those, the gallstone and the trauma related are the ones we got surgery involved. So if you want to comment on that, Tom, right, so it does really very much focus on the likely probable etiology of the pancreatitis. If it is trauma or if it is highly suspicious for gallstone pancreatitis, we will involve our surgeons and Jamie Nathan early in the course of that patient's hospitalization. Um, there definitely are other possibilities to and other considerations to involve them as well, um, including, um, uh, necrotic pancreatitis too as well, right. That's right, and so early involvement of our surg surgical colleagues is very important. OK, so I'll show you in brief. I'm not going to be able to cover the whole order set, but just to show you how we standardize things in the management. We really built it into making it user-friendly and incorporated the best evidence in management into, um, we use Epic and this is not, you know, a presentation about Epic, so we use their permission to get these slides up. Um, so. For the vital signs, for instance, we want them to be checked, checked very often the 1st 2 days, including pulse ox checks, because when we aggressively resuscitate, there are some evidence that shows that you could actually flood the lungs and result in pulmonary edema, and SERS by itself could do that. So we really are very watching. We're watching for this and we want the nurses to be aware of those complications. Again, nursing orders that they notify if there's decreased breathing, for instance, decreased urine output, because we want to use some goal directed management for the IV fluids. In terms of diets, there's all kinds of options and even if the physician, for instance, wanted to use the NPO, they could go and click these boxes. We check for them already though what we think is best practice, which is Start your patients on a clear liquid diet, and it's really a progressive transitional diet, so they start on a clear liquid diet. If it's tolerated within 6 hours, the patient is ready to order regular diet foraged food, and the nurses would give them the menu and they would just eat. We would not force them to eat if by the day 2 or 3 they're not eating, then we discuss internal feeding options. For IV fluids, we just add education points with the red that the evidence shows that the outcomes are better with aggressive resuscitation. We really defaulted our management to D5NS since we're using higher rates. We didn't want people to use half an S, so hypotonic solutions with the higher rates. So back to our patients, um, we did um kind of use that standard way of management that we use in the institution and mainly um when we divide the patients to who got You know, NPO and low IV fluids, NPO and high IV fluids and early PO and low IV fluids, early PO and high IV fluids. This is really a study when we studied 201 patients, we really showed that in terms of developing severe pancreatitis or even the associated outcomes, about 35% of the NPO and low IV fluids group could develop severe pancreatitis. Versus the ones who ate early and got aggressive resuscitation had a 4.2% association with severe pancreatitis. For that reason, really, our patient got 1.5 maintenance D5 normal saline over the first day, was eating and drinking, while by the next day we sent him home with oral as needed PRN medications after 52 hours of admission. The classic story, since we're talking about diseased pancreas, it can't be that easy, right? So he came back five months later, same patients with the same symptoms, and this time his lipase is even higher. It's 20,000 international units per liter. He also had other labs that could suggest that this is a severe course. He had a YPC that is elevated, albumin that is low, and a CRP that is high. So we got an ultrasound and you probably see that also in your own institutions and we see it too. I mean when 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, but this is really what we got. We didn't see anything on his pancreas. I mean, unfortunately the pancreas can be a little bit difficult to see sometimes. Especially in larger patients and as you say, in patients that are NPO, if you've got a stomach full of gas or if you have an ileus because there's a real inflammatory process going on, all that bowel gas can really affect the penetration of the ultrasound waves and make the pancreas non-visible. Additionally, if there's just a massive inflammatory process, all the inflammation can obscure the normal tissue planes and what we normally expect to see. Sometimes we can still sort of make a call and say, well this looks bad. We need to do something more like we're talking about before. Ultrasound is an initial assessment, screening test, and then recommend moving on to something more definitive like CT that gives us a good look at the anatomy and the adjacent structures. Absolutely, and I think I really have to say we're very blessed here that sometimes we don't see it. The radiology colleagues help us get the patient back on ultrasound. If that's still kind of a needed study, we give the patient a few hours and then repeat it. So this patient, we admitted him, we used the orders set, we allowed him to eat. He wasn't really eating. He couldn't eat. He said, I can't. I have no appetite. He was really sicker looking every day. On hospital day number 4, he was having tachypnia, so increased respiratory rate, severe belly pain. So day 4 is really not a time we like to see the patients taking this course. So what would you do next for this child? He's really not expected to have the classic recovery from acute pancreatitis, where you get an ultrasound, MRCP, CT scan, or ERCP, and this is a poll question, so please go ahead and submit your thoughts, um. So let's show the answer to our poll question. I'm interested to see what the audience chose to do for this patient. Oh, good. So it sounds like the majority chose the CT scan, and then even before you gave the answer. Oh yeah, yeah, that's awesome. And then MRCP 20% and ultrasound looks like people would repeat it in 20%. The ultrasound for necrosis, it's probably not your best choice, don't you think, Dr. Trout? Right, in a patient that you think has complications or has a particularly severe presentation, yes, maybe you could, if it's been 4 days, you could do another ultrasound to see if there's something there, but the high likelihood is you're going to have to go to a CT. And as we said earlier in the presentation, while MRCP does provide Ductal anatomy in the setting of an acute attack like this, the ductal anatomy can be obscured, and so the added value of MRCP is not so much in the acute setting like this. And as everybody knows, an MR takes dramatically longer than a CT scan does. And in these patients that can be sick and uncomfortable, asking them to lie on an MR scanner for 40 minutes can be a little problematic. One quick point about the CT exam in terms of how to protocol or order. Those exams, we simply do a portal venous phase. We don't do a multi-phase in the initial assessment of these pancreas, these patients. You're not in general in pediatric patients looking for masses where there's added value of having both the arterial and the portal venous phase. We're really looking for those complications venous thrombosis, necrosis, acute fluid collections, those sorts of things. We do try to get oral contrast on board in these patients. The main reason for that. is to help separate fluid-filled loops of bowel from fluid collections or acute fluid collections or developing collections in and around the pancreas. That said, if you have a sick patient who really cannot handle the oral contrast, you can get a lot of information without the oral contrast. And so that's not a deal breaker in my opinion in terms of how to do the CT in these patients. That sounds reasonable. So this is a selected CT or image from a CT scan in this patient, and again, Like what just said, this is a patient now at this point that we think that there's something more severe going on, and so CT is our test of choice here at this institution and should be your test of choice in those patients where you think there's complications going on. It really does give the best appearance or the best image or view of the lay of the land in terms of identifying complications, identifying effects on other structures, identifying issues that would potentially lead to surgical consultation or involvement of other experts. And what this CT image shows here, so there's an extensive inflammatory process in the belly here. The blue arrows show inflammation in the mesenteric and omental fat all around the pancreas. The pancreas is markedly enlarged and very abnormal in contour. The tissue planes around the pancreas are clearly abnormal, and the yellow arrow there is indicating an area of absent enhancement in the head and insonate process of the pancreas. And when we see absent enhancement like that, that's highly concerning for necrosis within the. Pancreas. So that's the diagnosis or the concern that we raised here. There is a small amount of ascites over here in the left hemiabdomen as well, which is a common thing that we see, or acute fluid in these cases of pancreatitis. OK, that's great. We do have a question from Dr. Alex Bondo, and the question is, is there any role in the modern era for using Ransom's criteria to predict mortality in pediatric pancreatitis? That's a great, great question. We currently do not apply ransoms directly to kids for the different um causes and limitations. You can start with age first, right? Um, the, the studies that try to do that earlier are really, they started in 2002, um, I believe with the Midwest study, so University of Cincinnati was part of it and um they applied that into kids. It was promising initially. It required 48 hours to be completed, but then when it was validated with further studies, it didn't pan out to be as sensitive and specific as they hoped. Later on, actually, there are some other studies that showed that maybe you could use lipase as a marker within the 1st 24 hours, and we just finished our study that talked about. Using prognostication markers on admission to predict severity, some of the ransoms elements are in there and some different ones are there too. So what we predicted using from our tool are mainly white blood cells. Count, albumin value, and lipase on admission, and those together in a formula could predict severity in almost 70% of the patients. Still needs to be optimized, but at least that's a promising direction we're going. OK, so good. Keep the good questions coming. So what should we do for this patient next? I mean, we diagnosed that. The patient has complicated pancreatitis with a possible necrosis and those kind of small tiny fluid collections. Would we just do observant management? Would we go ahead and drain it using EU US guided procedures? Would we consult interventional radiology for drainage? Use antibiotics, would we feed or not feed? And these are really the valid questions that go in our minds whenever we face these situations. So a few highlights again and to make it as high yield as possible from this and definitely keep the debates coming. The patient is afebrile. I don't think this is an infected necrosis, so we did not start antibiotics. Juvenile feeds were started because this patient could not tolerate anything in his stomach, and as clinical course improved, he was actually then allowed to do PO and he was eating by the end of the 10th day of his hospitalization. So to highlight antibiotics and acute pancreatitis, which is another hot topic, really we want to use them for mild. And in a case like this one, even when we had signs of severe, unless it's infected necrosis, we probably would not have a strong evidence to use it. And when we think about antibiotics, usually Emipenem or 3rd generation cephalosporins are the good initial choices again based on the evidence that we have out there. So his attack really, I would say resolved with conservative management, but we categorized him as having acute recurrent pancreatitis, and all the inflammation cooled down three months later. And this is his MRI 3 months later. Looks pretty good, huh? Yes, MRI. I got 2 images here from the MRI. Both are fluid sensitive sequences. There's a coronal image there on the left side and an axial image there on the right side. And again, now you have a patient who's cooled down, and now is the time. Where you can use MRI to assess for pancreatic ductal anomalies or other things that might be predisposing to the cases of pancreatitis or to the pancreatitis events, and what I'm showing with the blue arrows there in the figure is the body of the pancreas. The duct is a little bit prominent. It's this. White stripe. Sorry, I'm having trouble seeing my area. There we go. It's this white stripe running down through the body of the pancreas here. It's a little bit prominent. Generally in a healthy pancreas, you're not going to see the duct that well, and there is some atrophy and irregularity of the contour of the pancreas related to these prior attacks, but we're not seeing findings here that we would by imaging consider diagnosis diagnostic for chronic pancreatitis. Right, and we really use MRI MRCP quite a bit in the workup of acute recurrent. Um, so what is acute recurrent pancreatitis? For definition purposes, for the sake of studies and research, um, the InspireE Group, which is the International Study Group for Pediatric pancreatitis in Search for a cure, led by Dr. Aliyah Uchin, the University of Iowa. Gathered together the first time in 2009 and then later in 2012, we came up with definitions. What is acute recurrent pancreatitis in kids? So we said for the sake of consistency, it is at least two distinct episodes, and you need to have complete resolution of pain and a one month pain free interval between the episodes. Or if you have normalization. Of the enzyme between them with complete resolution of pain within less than 1 month, then that is diagnostic as well. Exclusion, of course, if there is a pseudocyst, then it doesn't qualify as acute recurrent pancreatitis until the cysts resolved. So the patient really recovered for 5 months and then presented with another attack. So in that case we have a very specific workup for acute pancreatitis that is. We think about inflammatory causes like IBD and celiac disease. We work them up for systemic illnesses and mitochondrial diseases, cystic fibrosis, metabolic conditions that predispose patients to acute recurrence like triglyceride elevation, calcium and kidney disease, anatomic, and that's the reason why we get an MRCP, possibly an ERCP. And Dr. Tomlin will cover that through cases next here in a minute, and then a genetic workup. The 4 genes that I listed here are the most common genes, and I will cover that more in the topic that comes in this session too. And then um it's really a very comprehensive workup, but we're trying to find causes that could be treatable or not treatable for the patients, but it's very, very important for counseling. When can I interrupt you? You can right now because I'm giving the podium to Dr. Lin so much. So we got to, so just tell me when to slow down here. So first of all, a question from Mira Mennon. Mira says the lipids thing. Can we go back to the lipids thing? Enteral lipids. You said there's really no data to show that it really is worth. What about the parenteral lipids? That shouldn't be a problem either, right? Yeah, when we use TPN, um, so you want to use some nutrition, right? Let's say in severe pancreatitis we absolutely failed. Have patients where we fail, so Enteral is better. We fail to even place an NJ because of how complex the pancreas is and the fluid collections, or there's complete duct disruption or whatnot. So we use TPN in certain situations, but rarely. We use intralipids with them. So Mira, now that you've heard this conversation, I want you to answer in the chat. Would you now reconsider using TPN as your standard and maybe move to En? I'm curious if that would change your management for me. I have a lot to bring back to my institution. Um, I hope you're writing a review article on all these things because I'm like tweeting like crazy here of all these new things I've just learned. So there are a few, but maybe we should update it. Uh, we'll, we'll help you if you want, if you want us to do the dirty work for you. All right, so the, the second question is, um, I noticed in your patient you did NJ feeds, so you still do it even though you found that it doesn't make a difference, so. NJ versus NG, no added benefit to the NJ compared to the NG, right? The classic teaching was get past the past the envelope batter. We don't believe that's the case from the evidence, but this patient really could not tolerate feeds in his stomach, so we, right? Yes, yes, and because we believe with severe pancreatitis, even the nutrition has added value, we still fed him kind of with an NJ, OK. Um, would you let them eat by mouth if they could tolerate it? OK, yeah, even in the severe if they can tolerate it, low fat diet or no, you just give them whatever they want. Honestly, we, we allow them to eat whatever they want. They usually don't choose the high fat diet the first day or two anyway. Yeah, got it. The questions are piling in here, but, uh, so. Talk to me through this is one thing I never understood. How do I know when to get an aspiration of the pancreas to rule out septic versus non-septic necrosis? What's your indicator to know when to do that step? If you see necrosis, do you do it all the time or only if they start getting really septic? I think it's a very interesting question. We could get a pancreas. Great. So how do you know when to only when needed. I've always struggled with that. That, that is, um, classically, you know, a very challenging question, um, you know, uh, you really, you can very much be opening a can of worms if you're starting to stick things into the pancreas. Um, I can tell you that I think we've had the need for one in the last 10 years, one necrosectomy for, for, you know, necro truly. Awful necrotizing pancreatitis, you know, clinical decompensation can be caused by a variety of circumstances. Um, you know, we're always quick to, to point at, you know, continued fevers, you know, do we stick a needle in the pancreas? You know, in the absence of true significant clinical deterioration, we, we really avoid, avoid sticking needles in the pancreas, sticking drains. Um, you'll see later on in the sessions we have had, uh, on occasion to stick drains into certain places to deal with clinical decompensation. But we are loath, loathe to intervene. Then can I take you through this, so this patient has, you get it, he doesn't get better, you get your CAT scan, you show necrosis. We don't know if it's sterile or we don't know if it's sterile necrosis or not. Do you just start antibiotics because you don't know? Do you wait for them to clinically deteriorate? Why even bother getting the aspiration if you think it is, just start the antibiotics? Yes, is that if that patient had a fever, I think I would start antibiotics. You think inflammatory antibiotics, I think empiric antibiotics would probably have a short threshold or low threshold for starting them, assuming it's infected, but you know there's, you know, there is a little risk, you know, you stick a needle into a collection that may be sterile and then you have the risk of introducing infection, and once you have infected necrosis. Things can can really deteriorate. So this would be one of those things that you're taught that's in the books, that's on the boards, but I don't see anyone really doing it that often. It's just treat with your brain more than, yeah, OK, yeah, um, what is this here? Yeah, OK, as you might suspect that there's a, there's an extreme limited amount of evidence as it relates to best management of necrotic pancreatitis in kids. Now for adults there's more evidence and there's growing evidence in terms of being more aggressive, especially. From an endoscopic standpoint for necrostectomy, endoscopic necrosectomy, um, and that evidence actually is showing very good positive outcomes in that regard. Now how do you do that for endoscopic or endo endoscopic endoscopic, yeah, so that's via endoscopic ultrasound actually transmural. So you, you do a gas, you open the stomach into the pancreas that that's already almost like a pseudocyst where it's right, right, right, very, very similar to that. So, so you, um. Enter the cavity, of necrotic cavity, and then there's the bridement of that from an endoscopic standpoint and obviously that can also be accomplished from a surgical standpoint too as well, but depending on the the other comorbidities of the patients and how stable they are, one option might be better than the other, but again, pediatric wise that. is extremely limited. Have you done that here? We have not. We have not. Fortunately we haven't had any patients that we still want to avoid it. We still want to, right, because to think that we're, you know, endoscopically draining a bunch of pancreatic acute pancreat, you know, pancreatic fluid collection. So do you use MR after secretin stem at this point? I think they're talking about back when the case when the patient sort of got worse, right, so we're going to talk a little later in the second session actually about how we do our exams with Secretin. We're still sort of feeling this out a little bit again. This is one of those areas where There's not great data in pediatric patients about the added value of Secretin. In fact, if you look at the adult literature, the data is a little bit iffy there in terms of the added value of the use of Secretin. There's a lot of case theories and anecdotes and things like that about improving visualization of ductal anomalies, but when you have it's. Often in the chronic pancreatitic patients or the acute recurrence that we're doing these MR exams and they've had enough attacks that generally the ducts dilated and you can see it without secretin, OK, but I'm not going to categorically say no to it again. There's still, we're still feeling out the evidence and trying to figure out exactly how to proceed. OK, all right, so uh Enrique, I hope that answered your question. Um, question between, uh, is there a relationship between BMI of a child and recurrent pancreatitis? Has that ever been studied? That's interesting. That's actually our next abstract that we submitted to World Congress. Wow. Where did that question come from? That came from Mira Mennon. OK, good job. So actually we have a prospective acute pancreatitis registry. We follow kids from the first attack onwards, and it's almost 3 years old now, and one of the first abstracts that we're very excited about is showing that the increased weight percentile for AIDS patients during the first attack. Not really the BMI, and I'll tell you why, does predict recurrence. Now we think that there is some evidence that the higher BMI does kind of predict severity. We haven't proved that yet in the US population, but there's enough in outside the world studies that higher BMI predicts severe pancreatitis course even in adults and in kids. The BMI didn't pan to be the case maybe. Because our patient sample was 85, the ones we looked at, but also it had a wide variation. We had heavy BMI patients on both ends, so the ones who did not develop recurrence and the ones who developed recurrence, and also we had the thin population, but the weight percentile for age was a predictor. OK, so great question. Next thing, so I have, for, by the way, Mira Mennon, after I asked her, she said. She definitely learned the point that you made and now she's going to move to enteral nutrition. I will too. Yeah, you've made a big impact. The question about, I have a question. The antibiotics that you would use, I know you, I think you said immipenem, Emipenem or cephalosporins based on that one study. OK, OK, yeah, cool. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Please send questions or comments to us attacurrent podcast@gmail.com. We'll see you next time.