Acute Pancreatitis

Pediatric Surgery
In this podcast, extracted from GlobalCast presentation, Dr. Maisam A. Abu-El-Haija discusses acute pancreatitis, along with participation from Drs Andrew Taut, Jaimie Nathan, Tom Lin and the audience. Dr. Abu-El-Haija is the medical director of pancreas care center, division of pediatric gastroenterology at Cincinnati Children's Hospital.

Topics discussed include imaging, lab work, diet and nutrition, nasogastric (NG) versus nasojejunal (NJ) feeding, fluid management, pain management, antibiotic use, and genetic evaluation.


Additional Content

Maisam Abu-el-haija is a pediatric gastroenterologist at the division of pediatric gastroenterology and the medical director of pancreas care center at Cincinnati Children’s hospital medical center.


01:23: Dr. Abu-el-haija: I will start by a case and to show you a real case from our practice when a nine-year-old comes to the emergency department because he has this sharp and tense belly pain, he rated at 7/10 it started two days before coming and he also has vomiting and I show the lab so the amylase was 100, our upper limit of normal in this institution is 109, and the lipase was 9800, and upper limit is about 199 or 200. So, does he need criteria for acute pancreatitis based on the criteria I showed you? We think he does but moreover we did get an ultrasound and I will let Dr. Andrew Trout comment on what we saw.

 02:09: Dr. Trout: we like to use ultrasound as our initial imaging tests in children where there's suspected uncomplicated acute pancreatitis and the value of ultrasound is that it is a radiation free modality gives you in general reasonably good look at the pancreas that said is a little bit limited in the setting where you are concerned about complications of pancreatitis.

02:28 Dr. Ponsky: which enzyme should we be using?

02:38; Dr. Abu-el-haija: It's not that the sensitivity is different early on, but amylase rises and normalizes much quicker than the lipase. If you remember the case we presented early, he had symptoms for almost two days, so that's what we commonly see the amylase might not be the best indicator. Lipase is more specific though, lipase has half-life is about seven days, but it's also more specific because it's mostly elevated if there's intestinal or pancreatic diseases, amylase could be due to appendicitis, obgyn, and salivary. So, amylase is less specific to the pancreas, but I think this is classically what we see.

Some people get a little bit confused when amylase is not elevated and you probably don't have pancreatitis. However, that can be classical presentation for pancreatitis.

03:35 Dr. Ponsky: I guess you use the ultrasound to assess gallbladder to make sure there's no stones, and the duct?

03:41 Dr. Trout, Correct, for sure you want to rule out potential causes such as pancreatitis and gallstones and obviously we are looking for those complications not to be fully characterized by ultrasound you may need to go to CT but at least give us an initial look if we see a lot of fluid if we see new areas it look like necrosis then we may consider going on another modality that point.

04:04 Dr. Abu-el-haija, Ultrasound is really the most helpful use of it is not really to document that the patient has pancreatitis are looking for complications is really looking if there's a biliary component. So, if there is CBD dilation then you would consider ERCP early or if there is goal stone that would change the whole management. So, further on with the history knowing that 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 a low-grade fever, sore throat, and myalgias. I just want to covering 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 we screen for complications and identifying gallstone. CT is the image of choice if we are thinking about a complicated case, it is a much better modality to better visualize the necrosis, fluid collections, hemorrhage, or masses. 

05:15: Dr. Abu-el-haija: MRCP, it is a very useful imaging tool will be showing through the talk today, through whole course the uses of MRCP in 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 MRCP for workup of these kind of biliary and pancreatic ductal issues.

05:55: Dr. Abu-el-haija: Talking about pain and we're very lucky that the way we managed even acute pancreatitis and Dr. Kenneth Goldschneider will elaborate more in management of chronic pancreatitis which you know the hallmark of the disease is pain. He helped us to incorporate what is best management for acute pancreatitis and we really built that based on the sparse evidence that we have available. So, what I would like to highlight from the 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 opioid. Actually, if you use them in the right patient and right setting even in acute pancreatitis that it is a connection advance needs and improve 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 acute sparing medications in pediatrics and we really need more trials on those.

07:02: Dr. Abu-el-haija: So, when I talk about the nuts and bolts of management okay you get the patient on what you going to do you can feed them or you can admit them or you send them home with IV fluid 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 the 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 syndrome (SIRS), or signs of multiorgan failure so that's really the majority of pediatric pancreatitis?

 1.  would you give them and feel for the first day to three days?

2.  would you keep them at bay until their lipase and amylase normalize so checking them every day until their normalized?

3.  would you keep them NPO until the pain is gone?

4.  NPO until they're off narcotics

5.  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, it's divided three ways between NPO for the first 24 to 72 hours as were most people wrote, and it was before you gave your answer, and the other people were divided between NPO until their pain is improved or gone which was my answer that's what I was and in so I already have learned three things that I want to tell you. NPO until they are off narcotics was another common answer.

 08:50: Dr. Abu-el-haija: So, nutrition is very important and actually the more we know about it, the more I am 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 which means 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 actually it lowers the incidence of systemic inflammatory response. Hence avoids having severe complications of pancreatitis. I will just do one make analysis because this is the strongest level of evidence we could have. This was in 2012 where they compared TPN versus enteral nutrition in the predicted severe acute pancreatitis and enteral really what's associated with better outcomes in terms of decreased organ failure and surgical intervention rate. These are forest plots shows that for mortality the analysis favored enteral nutrition and for infections the analysis favorite 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.


10:19: Dr. Abu-el-haija: Learning points. So far, I've learned that I was always afraid of opioids so that something I don't need to be afraid of anymore I thought it's because make the pancreas worse because sphincter of Oddi spasm, no good data, it's really conflicting that's an important key point to send out. Second thing, NPO until their lipase and amylases normalize which is what I see a lot. I think, the majority tends to do that, until pain is improved or their lipase and amylase, in other words they cool down the pancreas because everybody's afraid of aggravating the pancreas.


10:59: Dr. Ponsky: How do you feed them, you said enteral nutrition, they are going to through-up?

 Dr. Abu-el-haija: I think, I'll show you in a second we incorporated standardized every mild pancreatitis case gets the standard management, we made it easy on providers hospital wide we are 659 beds, almost 700 beds with the extension. So, it was very important to standardize how we manage the cases. These patients are under Hem/Onc floors, trauma, and obviously that's a different case in some aspects of because if the doctor is not in a continuity then you probably can't feed them but cardiac, G.I. and general peds. So, they go all over, and it was very important just to say allow the kids to eat, they are going to self-regulate and I'll show you the data in a second. That was the easiest one, we haven't gone to feed them aggressively, now when you get into the severe probably they are not going to be able to eat and that's where art comes to use some enteral nutrition mod to really expedite the healing without tipping things over.


12:05 Dr. Ponsky: So, you will show us this algorithm on how to use it.


Dr. Abu-el-haija: Yes, I'll show you something from our electronic medical record of how we make it easy on providers to order the standardized management. But, this could be again ordered on papers or elsewhere. This can be used in any other electronic medical record that the other institutions and share it with a lot of other institutions and found it very helpful.


So, we answered the poll question really that the answers were within the realm of what people were doing before we set a standardized management three years ago.


12:43: Dr. Abu-el-haija: Again, to Todd's question NG feed versus NJ feeds, really the majority of the studies shows no difference. So, the same outcomes on the duration of hospital stay and mortality were very similar. 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 benefits from inserting the NJ under fluoroscopy and sometimes these are difficult cases and going that route.


13:17: Dr. Abu-el-haija: This in the first in design and that's why I show it. In 2007 was when the concept of do not rest the pancreas came about. This is a study from Ekerwall GE, et al. where they did just simple in-design, randomized 60 adult patients, allowed 30 of them to eat on admission, and kept 30 of them NPO on admission. Really, the NPO was the classic method they managed the patient. Guess what they found? They found that you can feed without increased abdominal pain. So, you are going to wait on feeding your patients until the pain is gone, but their pain is going to be the same whether you feed them or not, and that's what the studies showed. Then the main outcome that they actually showed is a difference, which is a big thing for hospitals right now especially with the healthcare reform and everything that were going to in this era, they decrease the length of stay by two days in the group that ate earlier. So, that was very beneficial. if I show that to my hospital, they would love me, too. Everybody who hears us I'm sure. Patients would love it; it's a very important patient related outcome. So, 2 days earlier discharge in the group that ate and same pain scores in both groups and no harmful events. So, we replicated that in kids and this was just published on actually late in 2015. I just allowed the kids to eat like I mentioned, and 38 admission mild pancreatitis, we have shown that we can do that in case that early nutrition is safe and feasible and is not associated with pain outcomes. In fact, the patients who received feed than patients who are NPO had similar pain scores. These are patients who were evaluated multiple times per day, almost every four hours, subjectively and objectively by pain scores and they really had similar scoring assessment.



15:06: Dr. Abu-el-haija: Then we really want to look at whether fat intake. So, we start the patient feed on a low-fat diet and that's another thing that has been planted in our heritage, and I've been looking on the evidence that if anybody from the audience has a great point on that please feel and to call or send us your thoughts. I haven't found a good evidence for the low-fat. However, we know that that fat stimulates lipase and we don't want to increase lipase. But at least from this pilot analysis that we did we show here the lowest pain scores is pain score on the x axis or actually the ones who ate most fat. 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 second or third day and then you feel okay you are ready to go home.


16:06 Dr. Ponsky: Does fat intake increase the length of stay?


Dr. Abu-el-haija: So, we looked at the total hospital stay and really it didn't affect the length of stay.


16:15: Dr. Abu-el-haija: I think we probably talk and not 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 going to do? and we know that sometimes our surgical colleagues love the LR, and G.I colleagues love the normal saline (NS) and that's another debate too.


16:36: Dr. Nathan, when patient presents with emesis, we need to be clear that we are not force-feeding the kids that we are not pushing feeds in the face of ongoing emesis.


16: 50: Dr. Abu-el-haija: Our pain order sets that Dr. Goldschneider helped us built, we have narcotics sparing medications and I probably should change the name, right? I should say opioid sparing agents. We use IV Tylenol, 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.


17:29: Dr. Abu-el-haija: Another poll question: What would you choose IV fluid of choice for administration when you start a patient with acute pancreatitis on any IV fluids:

1.    would you not use IV fluids?

2.    would you have NS bolus followed by one times maintenance D5 NS

3.    would you have NS bolus followed by one times maintenance LR

4.    would you have NS bolus followed by more than one and half maintenance of D5 NS

5.    bolus followed by more than 1.5 LR maintenance.


So, almost 60% said the NS bolus followed by one and half times maintenance of LR, the other two responses were NS followed by one and half maintenance of D5 NS, and 1X time maintenance of LR. So, it looks like the majority are saying one and 1/2 LR. I agree, so the majority is awareness 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, but it's a very intriguing concept to be studied further, 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, they defined early aggressive as they calculated what is the 72-hour fluid volume for the patient and if the patient got more than 1/3 of that in the first day, it was counted as aggressive. Two studies at least showed beneficial in the event benefits, so it was associated with reduced mortality in the early fluid resuscitation was associated with reduced incidence of SIRS, and organ failure at 72-hours. Here, I showed a graph that shows that the SIRS, 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 early resuscitation group got. So, that puts the pressure that really you got a window and it's a 24 hour and if you don't interject then probably you lost your window, and more than 85% of patients really got NS. Another small study showed 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 that abstracts from Spain this year, they used LR versus NS and use the goal-directed management there they aggressively resuscitated until the urine output was at 3 ml/kg/hour, and the results showed that early resuscitation with LR did lead to reduce inflammation with certain transient receptor potential (TRP) markers compared to NS, so both groups got the same rate; one group got LR and the other group got NS and here's brings the question of should we all use LR? Again, this is one study.


20:58 Dr. Ponsky: Do you get the surgeons involved early in these patients or you usually manage them you guys and call surgery if there's a problem?


I think, Dr. Lin has a very good experience on the gallstone pancreatitis, gallstone pancreatitis and trauma-related are the ones we get surgery involved.

Dr. Tom Lin, it does very much focus on the likely probability of pancreatitis. If this trauma or if it is highly suspicious for gallstone pancreatitis, we will involve our surgeons and Dr. Jamie Nathan early in the course of that patient's hospitalization. There definitely are other possibilities and other consideration that involve them as well including necrotic pancreatitis, so early involvement of surgical colleagues is very important.


21:52: Dr. Abu-el-haija: I'll show you how we standardize order sets in the management were really built it into making it user-friendly and incorporated the best evidence and management into. We use EPIC and this is not in a presentation about EPIC, so we use their permission to get these slids up. So, for the vital signs for instance we want them to be checked very often in the first few days including the 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, SIRS by itself could do that that we really are very watching, we're watching for this and we want the nurses to be aware of those complications. Again, nursing orders and that they notify if there is decreased breathing for instance, decreased urine output because we want to use some goal-directed management for the IV fluids.


In terms of diet there's all kind of options and even if the physician for instance want to use the NPO they could go and click these boxes, we checked for them already there 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 six hours the patient is ready to order regular diet for age, and the nurses would give the menu and they would just eat. We would not force them to eat it by the day two or three they're not eating then we discuss enteral feeding options. For IV fluids, we have just added education points that evidence shows that outcomes are better with aggressive resuscitation, we really defaulted our management to D5 NS, since we are using higher rates, we didn't want people to use 1/2 NS, so hypotonic solutions with a higher rate.


23:49: Dr. Abu-el-haija: Back to our patient, we did use standard way of management that we use in the institution and mainly when we divide patients to who got NPO, low IV fluid, and NPO and high IV fluids in early PO and IV fluid early PO 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 who ate early and got aggressive assist station had a 4.2% association with severe pancreatitis, for that reason really our patient got one and half maintenance D5 NS over the first day with eating and drinking well by the next day we sent him home with oral as needed prn medication after 52 hours of admission.


24:50: Dr. Abu-el-haija: Since we are talking about disease pancreas that can't be that easy so he came back five months later same patients with the same symptoms in 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 WBC that is elevated, albumin that is low, and the CRP that is high. So, we got an ultrasound and you probably see that also in your own institutions and we see it too when the patients are not NPO enough time, I don't know Andrew if you want to comment, why sometimes we get the nonspecific findings or not adequate to comment, but this is really what we got we didn't see anything on his pancreas?


25:37 Dr. Taut: the pancreas can be a little bit difficult to see sometimes especially in larger patients and as you say in NPO patients, if you had a stomach full of gas, or if you have an ileus because it is a real inflammatory process going on all that bowel gas can really affect the penetration the ultrasound waves and make the pancreas nonvisible. Additionally, if there is massive inflammatory process, all the information 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 what we were talking 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 adjacent structures.


26:17, Dr. Abu-el-haija: I really have to say we are very blessed here that sometimes we don't see it, radiology colleagues help us get the patient back to ultrasound that still kind of a needed studied we give the patient a few hours and then repeat it. So, this patient admitted him, we used the orders that 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 sicker looking every day on hospital day number four he was having tachypnea, increased respiratory rate, severe belly pain. So, day four is really not a time we would like to see the patients taking this course. So, what would you do next for this child? he's not expected to have the classic recovery from acute pancreatitis would you get an ultrasound, MRCP, CT scan, or ERCP? and this is a poll question so please go ahead and submit your thoughts. The answer to our poll question, I'm interested to see what the audience chose to do for this patient. Good, that sounds like the majority chose the CT scan, MRCP 20% and ultrasound 20%. So, for necrosis, US probably is not the best choice, what do you think Dr. Trout?


27:39: Dr. Trout, right as you think it has complications or severe presentation maybe you could if it's been four days, you could do another ultrasound to see if there's something there, but the high likelihood you have to go to a CT, and as we said earlier in this presentation while MRCP does provide ductal anatomy in a setting of an acute attack like this, the ductal anatomy can be obscured and so that the added value of MRCP is not so much in the acute setting like this, and as everybody knows MRI takes dramatically longer than a CT scan does, and in these patients 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 patients, you not in generally pediatric patients looking for masses where there is added value of having both the arterial and the portal venous phase. We really are looking for those complications: venous thrombosis, necrosis, acute fluid collection, so sort 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.


29:07: Dr. Trout: this is a selected CT or image from a CT scan in this patient and again like we 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 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 for the best image review of the lay of the land in terms of identifying complications, identifying effects on other structures, identify issues that would potentially lead to surgical consultation, or involvement of other experts. What the CT image shows, so there is 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 area of absent enhancement in the head and uncinate process of the pancreas when we see absent enhancement like that that's highly concerning for necrosis within the pancreas, and so that is the diagnosis, or the concern that we raised here. There is a small amount of ascites over here in the left hemi abdomen as well which is a common thing that we see or acute fluid in these cases of pancreatitis.


30:18, Dr. Abu-el-haija: Dr. Alex Bondoc’s question, is there any role in the modern era for using Ranson's criteria to predict mortality in pediatric pancreatitis? That is a great question. We currently do not apply Ranson’s directly to kids for the different causes and limitations you consult with age first, right? The studies that try to do that earlier they started 2002, I believe with the Midwest study, so university Cincinnati was part of it. They applied that to 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 hope. Later on, actually, there are some other studies that showed that maybe you could use lipase as a marker within the first 24 hours, and we just finished our study that talked about using prognostication markers on admission to predict severity. Some of the Ranson’s elements are in there and some different ones are there too so what we predicted using, from our two alarmingly white blood cell count, albumin value, and lipase on admission and those together in a formula could predict severity and almost 70% of the patient. It is still need to be optimized but at least that's a promising direction we are going.



31:57, Dr. Abu-el-haija: What should we do for this patient next? We diagnose that the patient has complicated pancreatitis with possible necrosis and those kind of small tiny fluid collections. Would we do just observant management, would we go ahead and drain it on using EUS guided procedures, would consult interventional radiology for drainage, would we use antibiotics, would we feed or not feed? These are the valid questions that go in our minds whenever we face these situations. So, few highlights again to make it as high-yield as possible from this and definitely keep that debate coming; the patient is afebrile, I don't think this is an infected necrosis so we did not start antibiotics, jejunal feeds were started because this patient could not tolerate anything in his stomach, and as the clinical course improved he was allowed to do PO and he was eating by the end of that 10th day of his hospitalization. So, to highlight antibiotics in acute pancreatitis, which is another hot topic, we won’t use them for mild and in a case like this one even when we had signs of severe, unless we have infected necrosis, we probably would not have a strong evidence to use it. When we think about antibiotics usually imipenem or third-generation cephalosporins are the good initial choices. Based on evidence that we have out there. So, his attack was really, I would say resolved with conservative management, but we categorized him as having acute recurrent pancreatitis, all the inflammation cooled down three months later, and this is his MRI three months later. Looks pretty good.


33:38 Dr. Trout: I got two images here from the MRI, both are fluid sensitive sequences there's a coronal image there on the left side in an axial image there on the right side.  Again, now you have a patient whose cooled down and now is the time we can use MRI to assess for pancreatic ductal anomalies or other things that might be predisposing to the cases of pancreatitis events. What I am 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 running down through the body of the pancreas here it is a little bit prominent. Generally, and in a healthy pancreas, you're not going to see the duct that well. There is some atrophy and irregularity of the contour of the pancreas related to these prior attacks, but we are not seeing findings here that we would by imaging consider diagnostic for chronic pancreatitis.


34:28 Dr. Abu-el-haija: Right. We really use MRI/MRCP quite a bit in the workup of acute recurrent. So, what is acute recurrent pancreatitis? For definition purposes, for the sake of studies and research; The Inspire Group, which is the international study group for pediatric pancreatitis and in search for a cure led by dr. Elliott in university of Iowa gathered together 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 enzymes between them with complete resolution of pain within less than one 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 assess results. So, the patient really recovered for five months and then presented with another attack. In that case we have very specific workup for acute pancreatitis that is recurrent. 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 recurrent-like triglyceride elevation, calcium, and kidney disease, anatomic and that's the reason why we get an MRCP, possibly an ERCP. Dr. Tom Lin will cover that through cases next here in a minute.


36:07: Dr. Abu-el-haija: Genetic workup the four genes that I listed here are the most common genes, and I will cover that more topic that comes in for session 2. Then, it's really a very comprehensive workup, but we are trying to find causes that can be treatable or not treatable for the patients, but it's very important for counseling.


36:28: Dr. Ponsky: A question from Miraminin. Mira says regarding enteral lipids, you said there's really no data to show that…, what about parenteral lipids that shouldn’t be a problem either right?


Dr. Dr. Abu-el-haija: So, you want to use some nutrition, right? let's say in severe pancreatitis we absolutely fail, we have patients where we fail. So enteral is better, we fail to even place in NJ because of how complex that pancreas is and the fluid collections, or there is complete duct obstruction and what not, so we use TPN in certain situations. We use intra-lipids with them.


37:15 Dr. Ponsky: So, Mira now that you've heard this conversation I want your answer in the chat; would you now reconsider using TPN as your standard and may be move to intra? I am curious to know if that would change management. For me I have a lot to bring back to my institution.


37:42 Dr. Ponsky: The second question is: 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?


37:54 Dr. Abu-el-haija: So, NJ vs NG, no added benefit to the NJ compared to the NG, right? The classic teaching was to pass the ampulla of Vater, we don't believe that's the case from the evidence. But this patient really could not tolerate feeds in his stomach, because we believe, with severe pancreatitis event, the nutrition has added value we still fed him with an NJ.


38:18 Dr. Ponsky: Would you recommend by mouth if he could tolerate it?


Dr. Dr. Abu-el-haija: Yes, even in the severe case if they can tolerate it.


38:24 Dr. Ponsky: Do you give a low-fat diet or you just give them whatever they want?


Dr. Abu-el-haija: Honesty, we allow them to eat whatever they want. They usually don’t choose the high-fat diet the first day or two after anyway.


38:34 Dr. Ponsky: 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?


Dr. Abu-el-haija: I think is a very interesting question.


39:06 Dr. Nathan: That is classically a very challenging question, you know. You can be very much opening a can of worms if you're starting to stick things into the pancreas. I can tell you that I think we have had the need for one necrosectomy in last 10 years, for a truly awful necrotizing pancreatitis. You know, clinical decompensation can be caused by a variety of circumstances, we are always quick to point at continued fevers, do we stick a needle in pancreas? In the absence of true significant clinical deterioration, we really avoid sticking needles in the pancreas or sticking drains. You will see later on in the sessions we have had on occasion to stick drains to certain places to deal with clinical decompensation, but we loath to intervene.


40:02 Dr. Ponsky: can I take you through this patient, he doesn't get better, you get your CT scan, you are shown necrosis. We don't know if it's sterile or not. Do you just start antibiotics because you don't know, do you wait for them to clinically deteriorate? Why do you even bother to getting aspiration if you think it is? Do you start the antibiotics?


24:25 Dr. Abu-el-haija: If that patient had a fever, I would start antibiotics.


24:30 Dr. Nathan: I think empiric antibiotics will probably have a short threshold for starting them


Dr. Abu-el-haija: assuming it is infected.


Dr. Nathan: But there is a little risk you stick a needle into a collection that may be sterile and yet have the risk of introducing infection. Once you have infected the necrosis things can really deteriorate.


40:49 Dr. Ponsky: This would be one of those things that you're taught, that's in the book, that is on the boards, but I don't see anyone really doing it that often. It is just treat with your brain.

41:01 Dr. Lin: There is an extreme limited amount of evidence as it relates to the best management of necrotic pancreatitis in kids. For adults, there's more evidence and there is growing evidence in terms of being more aggressive especially from endoscopic standpoint endoscopic necrosectomy and that evidence actually showing very good positive outcomes in that regard.


41:26 Dr. Ponsky: How do you do that?


41:92 Dr. Lin: Endoscopic. So, endoscopic ultrasound actually transmural.


41:36 Dr. Ponsky: So, you open the stomach into the pancreas that's almost like the pseudo-cyst where?


41:43 Dr. Lin: So, you enter the cavity of necrotic cavity and then there is a debridement of that form from an endoscopic standpoint. That can also be accomplished from a surgical standpoint as well. But, depending on the other comorbidities of the patient and how stable they are, one option might be better than the other. But, again pediatric wise that evidence is extremely limited.


42:06 Dr. Ponsky: have you done that here?


42:08 Dr. Lin: Fortunately, we haven't had any patients.


42:20 Dr. Ponsky: Do you use MR after secretin stem at this point? I think you're talking about back when the case from the patient sort a got worse


42:30 Dr. Trout: Right, so we are going to talk a little later on in the second session about when we do our exams with secretin. We are 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 adult literature the date is a little bit iffy there in terms of the added value of the use of secretin, because a lot of case series and anecdotes and things like that about proving visualization of ductal anomalies. But, it's often in the chronic necrotic patients with acute recurrence that we are doing there MRI exams and they've had enough attacks that generally the ducts dilated and you can see it without secretin. But, I am not going to categorically say no to it. Again, there still we are still feeling out the evidence and still trying to figure out exactly how to proceed.



43:19 Dr. Ponsky: Is there a relationship between BMI of a child and recurrent pancreatitis, is ever been studied?

 43:24 Dr. Abu-el-haija: That is interesting, that is actually our next abstract that we are submitting to the next conference. 

43:33 Dr. Abu-el-haija: 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. One of the first abstract that we are very excited about is showing that the increased weight percentile for age 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 to that the higher BMI does kind of predict severity, but we haven’t improved that yet in the US population. But there is enough data in the outside world studies that higher BMI predicts severe pancreatitis course, even in adults and in kids. The BMI didn't pan to be the case, may be because of our patients’ sample with 85, the ones we looked at, that also had a wide variation; we had heavy BMI patients on both ends, the ones who did not develop recurrence and the ones who develop recurrence. Also, we had the thin population. But the weight percentile for age was a predictor.


44:40 Dr. Ponsky: Okay, Miramini, after I asked her, she said she definitely learned the point that you made and now she's move to enteral nutrition, you made a big impact.


44:55 Dr. Ponsky: I have a question, the antibiotics that you would use; I think you said imipenem?


45:01 Dr. Abu-el-haija: imipenem or cephalosporins, based on that one study evidence that you got.