Behind the Knife, the surgery podcast, relevant and engaging content designed to help you dominate the day. Hello, everyone, and welcome to the next episode in our series on emergency general surgery. Today, we're going to focus on one of the most challenging diseases in all of emergency general surgery, pancreatitis. But before we get into that, it's my pleasure to welcome back Dr. Marika Sevigny, who has agreed to join our team full time. Welcome, Marika. Thank you, Ashley. Hello, everybody.
We are so happy to have you on the team and permanently, of course. And I'm joined once again by Jordan and Graham. Hi, everyone. Hey, Ashley. Hey, everybody. Glad to be here. Glad to be talking about pancreatitis, a disease that we're all pretty familiar with. The reported incidence of pancreatitis is around 50 out of every 100,000 people annually. But I got to say, in my practice, it sure seems like a heck of a lot higher.
For sure. I'm not sure if that's because patients with pancreatitis can get so sick, or if it's the fact that the complications lead to such long hospitalizations. But we sure do spend a lot of time talking about and treating patients with pancreatitis.
Yes, we do. I think pancreatitis is an interesting disease because we're all pretty comfortable making the diagnosis. As a review, you need two of three things. A good story, elevation in lipase or amylase greater than three times the upper limit of normal, and suggestive imaging. I think we're also pretty good at the early management, including fluids, multimodal analgesia, and early enteric feeding. But beyond that, there's things that can get a bit tricky.
I'm so glad you said that, Ashley, because I find the next phase of management really, really hard. You know, you've made your diagnosis, you've resubstated your patient, and hopefully you've admitted them to the right place. And that's when I find things just start to happen. So the patients get febrile, their pain starts to get worse, their white blood cell count goes up, and everybody's asking you what to do.
I often think about should I start antibiotics? Should I culture the patient? When should I rescan them? How do you guys decide? For sure, Graham, and the decisions only get harder. How are you going to decide whether or not to put in a drain? If you do put one in, how are you going to decide when they need another?
When are you going to upsize? What if they're still not getting better even though you did all these things? I know, right? And there are so many different kinds of procedures. There are endoscopic procedures, retroperitoneoscopic procedures, and some...
Good old laparoscopic and even open surgeries. So many options, but which patients should get them? Who should be the one performing them? And what should the timing be? Can we just skip to the good part where I get to take out their gallbladder? Not so fast, Graham. Plus, that's only for patients with gallstone pancreatitis, obviously. Well, what about after scorpion bites? No, we're not talking about scorpion bites. This isn't animal planet. We're talking about common problems.
Okay, fine. Well, don't worry. There's still tons to talk about, but two great cases today that we think will really tease out the nuances that are critical to the complex management of patients with pancreatitis. All right, so let's go ahead and start with our first case. And this is one that's based off a case I saw while I was a junior resident and has been burned in my brain for years. In a good way or a bad way?
Well, we're talking about surgical management of pancreatitis, so I think you know the answer. Yeah, I really think this case highlights the potential complexities in what is often thought to be a simple process. But I'm not giving anything away right now. You're all going to have to work through this one.
All right, let's hear it. The patient is a 30 year old previously healthy female who presents to a community hospital with a one day history of severe nausea and abdominal pain in the epigastric and left upper quadrant area. She hasn't been able to take anything orally since the pain started and she's had frequent vomiting. This is in the context of having had a weekend of uncharacteristic partying with friends where she admits to binge drinking behavior over the course of two days.
for a bachelorette. On exam, she's tender in the epigastrium, but her vital signs are normal. Her initial lab work reveals hyponatremia with a sodium of 124 and a lipase of greater than 600. Her LFTs are all normal. She's diagnosed with alcohol-related pancreatitis and referred to medicine for admission. Ashley, at our institution, this would probably be the case, right? Not all pancreatitis comes to surgery.
Yeah, that's right. It's probably institution-specific, but at our hospital, if there's a strong history of alcohol and no evidence of gallstones, it would go to medicine. Although this patient has an acute history of alcohol use, which is interesting.
She didn't have an ultrasound initially, a diagnosis. Do you think that all patients presenting with pancreatitis should have this done? I would say it's important to rule this out, even with a history of alcohol, because it's one of the most common causes of pancreatitis.
Jordan, what about your center? Would you have this case referred to surgery or medicine? Does all pancreatitis go to surgery where you're at? Yeah, great question. Because this is an area that everybody argues about, of course.
So in my center, gallstone pancreatitis tends to go to surgery, and non-gallstone, usually alcohol-related, goes to medicine, similar to what you were saying. That being said, I think that any patient with severe acute pancreatitis or with substantial complications of pancreatitis...
in my opinion, it should be managed either by surgery or by a multidisciplinary group, and I'll talk a little bit more about that later, to ensure that they get the best possible intervention when it's needed. Furthermore, I worry a little bit.
about idiopathic pancreatitis and not going to surgery, as I think the possibility of pulicistectomy for potentially undetected stones or sludge in the gallbladder as a cause should at least be discussed with those patients. Thanks, Jordan. Those are all really great points. So this particular patient is admitted to medicine. She's resuscitated with IV fluids and pain control with a plan for discharge home once tolerating a clear fluid diet.
They also send a basic workup, including triglyceride levels, which, interestingly, does come back as significantly elevated, and she does eventually go on to have an abdominal ultrasound, which reveals the presence of a single mobile gallstone. Again, they anticipate a nice short admission. Sounds great, but yeah, something tells me it's not going to pan out that way. The next day, she's not improved. Her pain is so severe she started on a PCA pump.
Over the next few days, she gets much worse and develops severe hypocalcemia, and her white blood cell begins to climb to 19.5. On post-admission date 3, she becomes tachycardic to the 140s and diaphoretic with subjective dyspnea.
Her blood pressure remains stable throughout this. She goes for a CT scan which reveals severe pancreatitis with peripancreatic stranding, moderate ascites, some fluid in the lesser sac, but uniform enhancement of the pancreas. At this point, general surgery is finally consulted. Graham, what would you do at this point?
Well, it seems as if the clinical picture fits with the imaging we've got. She's got some bad pancreatitis, but there isn't really anything surgically to offer at this point in the absence of any obvious infection. So in this phase, really the focus is all on supportive care. management of her systemic inflammatory response and supportive care of any organ dysfunction, if you find it. It doesn't sound like we have any evidence of that at this point, though. No, no, not yet.
Okay, so that's exactly what they do. She gets an additional 2 liters of fluid, ongoing pain control, and her heart rate does respond. Oh, that's great. That's so fast. On post-admission date 5, she develops fever to 39 in the evening and acute tachypnea. Her abdomen is noted to be increasingly tense and distended and tender. She's eventually transferred to the ICU for further management.
Blood cultures are drawn and reveal ESBL bacteremia in the blood and urine. Again, another CT scan is done. And this time they actually did a CTPA as well because of that tachypnea. And it didn't show any major changes or pulmonary embolism. All right, Ashley, what are your thoughts now? Are there any findings of keg-gratic necrosis, abscess, or pseudocysts at this point on imaging?
No, there's a little bit more fluid in the lesser sac and around the transverse mesocolon, but nothing organized. Okay, well, it sounds like there may be another source for the ESBL with the two positive pledgers. and the relatively normal scan so i'd make sure she's been pan cultured completely and start her on antibiotics from bacteremia but there's still nothing to act on in the abdomen at this point
Okay, so she is started on neuropenem, but remains febrile to 39 for several days. And you're getting multiple calls a day from ID and ICU about this, that her abdomen is distended, it's tense, she's tachycardic, febrile. What are you going to do? You got to do something. Yeah, this definitely happens a lot, but we know severe pancreatitis causes a pronounced systemic response and fevers and tachycardia can be expected. We just have to make sure we're not missing infection.
so even with all that lesser stack and retroperitoneal fluid still nothing this is medicine pressuring you okay i'm doing my best impression not necessarily me that's a pretty solid impression right No, it's too early. And again, there's no abscess or infected fluid collection or really anything to target. Placing a drain is not without harm. Draining a sterile collection can produce iatrogenic infection, worsening the patient's prognosis.
So we're only a few days out from the onset. This isn't going to help at this point. I'm usually doing everything I can to avoid intervening with this current picture. I'd continue to focus on ensuring she's resuscitated and ensuring nutritional support if she hasn't been eating or hasn't been served on feeds. And that could be NG, NJ feeds or TPN.
Absolutely. And although I completely agree with that plan, I think it's important to remember that we're constantly on the lookout for changes that imply surgical management might be needed. Is the abdomen so tense that the patient needs to develop abdominal compartment syndrome? Is there any indication that the transverse colon here might be ischemic or perforated as a result of the pancreatitis? Is the fluid no longer adjacent to the pancreas retropericneum?
um and larger in volume is there some chance that you know there could be a large duct disruption or pancreatic ascites these are all questions that keep me up at night but i digress Sounds like all things you've probably faced at some point, though, in your practice. Yes, unfortunately, yes. Okay, so for this case, it sounds like we're sticking this out. Unfortunately, though, for this...
young lady. Two days later, she's intubated for respiratory distress. We're now at post-admission day eight or so, and she's re-scanned on post-admission day 10. And again, still no changes. Yeah, I feel like this happens a lot, but that's a lot of scans for this young woman in a short period of time. Agree. And you may not expect to see much change within the first week.
Yeah, for sure. When a patient's sick, I know it's hard to resist though. We want to keep looking for alternative explanations or something that'll explain away what's going on, but we need to know exactly what's going on inside the belly.
As much as we worry about this repeated CT exposure, I think we need to strongly consider a repeat scan whenever we have any significant clinical change. I'll take a very small interval risk related to radiation exposure or we're missing a perforated colon any day. That's a good point.
All right, but in this case, nothing's really changing. The pancreas is still angry, but homogeneously enhanced. There's still small volume of retroperitoneal fluid on the skin. Would you tap this fluid yet, Ashley? Still no. There's no sign to suggest it's infected. Leave it alone. Alright, so she does improve from a respiratory perspective. She's extubated, transferred back to the ward about a week later.
However, she continues to have an ileus, abdominal pain, and these intermittent fevers that will not settle. When would you rescan her? Graham? Yeah, I mean, I agree with everything you've said. I really try and wait if I can. Generally, necrosis and infection occurs within two to three weeks after the onset of symptoms.
So we should really be thinking about repetitive CT scans being performed according to the evolution of the patient and not in some sort of pre-programmed way. It's pretty rare for necrosis to occur early on. something that we should be suspect we should be suspecting if their sears response persists or recurs after 10 days to two weeks so we're at the three week mark more or less now
Okay, yeah. So if she's still unwell and having fevers, then I guess I'd consider re-scanning her. Ashley, what do you think? Yeah, I agree. Especially if she was improving, came out of the ICU, and now she's grumbling along again. Okay, so a CT scan is ordered and done, and now it shows an enlarging retroperitoneal fluid collection, which is septated and has multiple loculations, and there's clear enhancement around this collection.
And it's also happened to be displacing bowel loops, and there's reactive alias around this well-encased collection. Gotcha. And what's going on with the pancreas now? It's still homogeneously enhancing. What do you do now, Jordan? Yeah, these are incredibly tough scenarios. I find that patients, families, colleagues often look to us for answers here and for an intervention that's going to fix the problem.
So I often start with a conversation and setting expectations for patients, families, colleagues alike. This is going to be a long recovery, there's likely going to be multiple interventions, and sometimes it's going to feel like we're doing nothing, but that doesn't mean that we are. It usually means we're waiting for the right time to act.
the right way to act, and we're trying to avoid the harm of unnecessary, unwarranted interventions. Additionally, here at our center, the Health Sciences Center of Winnipeg, We're the pancreatitis referral center for the whole province. So we're fortunate or unfortunate, depending on your point of view, to have a huge catchment for pancreatitis patients. So as a result, we have a local multidisciplinary pancreatitis group.
All patients with severe or complicated pancreatitis get discussed by multiple surgeons, advanced endoscopists, radiologists, HPB colleagues. and we talk about all these patients before any, of course, non-emergent intervention is undertaken. And that way we do our best to ensure that we're planning for the right intervention from the beginning.
I found this extremely effective and I would advocate for a similar program wherever it's feasible. Now, in this case, we're still very early in the patient's course. We have a fluid collection adjacent to the pancreas with no... and it had radiographic signs of infection, but the rim enhancement is a little bit concerning.
Also, the collections are presumably not yet mature at this point, but they are causing compression of the adjacent structures. It's probably like gastric outlet obstruction and duodenal obstruction typically, but of course depends a little bit on the location of the fluid. So if this patient isn't tolerating oral intake, I'd be fast to move to a nasal jejunal tube and try and bypass the area of relative obstruction and keep them nourished. I wouldn't go after the collections yet.
and if the ng feeds fail i'd move to tpn and continue to wait it out in the absence of any clinical changes that force your hand i wouldn't typically suggest an fna or percutaneous sampling of the fluid to assess for infection but it is sometimes done certainly well described This patient's almost certainly going to need some sort of surgical or endoscopic intervention, but today is not the day. Okay, that's really helpful.
Generally, CT has a high sensitivity for radiographic signs of infection, but gas in the collection only appears in 12-22% of infectious cases, so that's not the only thing to look for. So we have to also go on the signs of infection, persistent fevers, increasing WBCs, CRP, in order to diagnose a secondary infection of pancreatic or peripancreatic necrosis.
If there's ongoing diagnostic uncertainty like there is in this case, I don't think it's wrong to obtain a sample via FNA. Great. And, you know, in this case, that's actually what they did. They did a diagnostic aspirate of the fluid and sent it to... for culture and it came back positive all right well at this point i think we have a pretty clear source of infection then so i think we're obligated to start antibiotic therapy
Although I would still favor avoiding surgical endoscopic intervention at this point because it's still quite early. In the absence of a clear final culture, what bugs are you covering for? Yeah, so the bugs most commonly involved are going to be things like E. coli, Enterobacter cloacae, E. fecalis, bacteroides.
So the antibiotic of choice for empirical treatment should be potentially carbapenems. They're thought to penetrate the pancreatic necrosis relatively well. So mirapenems are quite suitable. Now there's lots of other options and different regimens that you can use.
And I would certainly recommend involving your infectious disease colleagues. And of course, you're going to want guidance from the cultures and the bugs you grew as well. Okay. So her culture came back as ESBL. They treated with appropriate IV antibiotics. I mean, some patients do get better with this alone. I've seen it. That's true. A small proportion of patients can get better with IV antibiotics alone and don't need further intervention.
Once again, I get the feeling that that's not going to be the case here. Nope. She continues to grumble. She remains febrile and eventually does get a repeat CT on post-admission day 31 and basically looks like there's been absolutely no improvement. Still multiple fluid collections in the retroperitoneum.
Yeah, this is getting to look like more of a mess. Sounds like we're heading towards more interventions. Yeah, and I think I'll move ahead a bit because I want to get to the good part. I can't imagine this case has a good part. She stays in this community center for weeks with multiple attempts at draining the collection. She also undergoes paracentesis and placement of intra-abdominal drains in the right lower quadrant and lower abdomen for free fluid.
I mean, it is important to ensure that this fluid is in pancreatic ascites, and thankfully, it's never lipase-rich in this case, so it's not. But she does eventually have another further drain case in the retroperitoneal collection via the flank. A repeat CT eventually shows extensive pancreatic necrosis and large retroperitoneal collection. One is on the right side, 12.5 by 6.3 by 23 centimeters, and that's where the drain is placed.
but it doesn't seem to be getting smaller, so the drain isn't really working. And then the other collections in the left retroperitoneum, and that's also pretty big, 23.7 by 12 by 10 centimeters. At this point, now I think two months of being in the hospital, the HPV surgeon locally is consulted. At this point, just so I understand, she got one drain in the right retroperitoneum and two inch abdominal, but nothing in that left-sided collection? Yeah, that's correct. Okay.
So I think at this point, we have multiple complex collections, and we really need to give some thought about what the next few steps are going to be and how we're going to best facilitate complete control of the collections and the associated infected pet graft macrosam. Unfortunately, our possible interventions sometimes get hamstrung by the existing placement of drains, especially if they're placed without forethought as to what our eventual interventions are going to be.
And that, you know, of course, may relate to whether they're transabdominal, retroperitoneal, transgastric, whatever. and our options for definitive management may change as a result. So first things first, I would discuss this in detail with our multidisciplinary team and some of my more experienced colleagues. Definitely. And we should remember that any further drains or upsizing of existing drains should be done.
with our plan definitive management in mind. When possible, we should favor the least invasive, effective intervention with a general preference of endoscopic, percutaneous, then minimally invasive retroperitoneal. then open or laparoscopic, transgastric, or otherwise. And finally, open transabdominal resection and de Bruinand as the last resort and the most morbid option.
Yeah, I agree. And again, as per step up, the minimally invasive approach is the best. The ideal approach is whichever can safely achieve our goals of both controlling infection and local regional complications while minimizing morbidity. In our particular case, the bulk of these collections and the pancreatic necrosum are directly within or adjacent to the retroperitoneum, so planning for percutaneous drain placement through the retroperitoneal route.
with plans ultimately for a VARD or a video-assisted retroperitoneal debridement aided by these drains, would likely be the best way to go. So skipping all the way ahead, they do eventually place a total of four drains. This includes bilateral retroperitoneal drains, and the ineffective intra-abdominal drains are eventually removed, and she's transferred to an HPV center for ongoing management.
There, she does ultimately go on to get bilateral VARN procedures with pancreatic debridement, removal of all the infected necrosis, and drainage of the collection. She does ultimately get better, but she ended up spending the better part of a year in hospital before this is all said and done. Oh, wow. That's a rough course, but I'm still wondering, did the gallbladder come out?
Actually, yes. Once she had recovered, she was in fact brought back for a lap coli, if you believe it. Unfortunately, she had so many adhesions that they had to bail out on that first procedure. and she got brought back for an open palestectomy, which, again, terrible, lots of adhesions, but the gallbladder did come out. Well, I guess that's a happy ending-ish.
All right, so let's move on from one challenging pancreatitis case to another. The layers of complexity seem to be endless. So now we have a 67-year-old woman with a history of hypertension and a previous hysterectomy. who's admitted to the ICU for gallstone pancreatitis. She's febrile and tachycardic, but normotensive, thankfully. Her white count is 17 and her lactate is 4, but her liver function tests are within normal limits.
She has a CT that was done within 24 hours of admission that showed significant peripancreatic inflammation. An ultrasound confirmed gallstones, but no dilated intrapodic or extraplodic docs. Okay, well before anybody asks me, I'm going to say I would just make sure that she had two large borough IVs, a foley to monitor her urine output, that she was receiving appropriate IV maintenance fluids and boluses to keep up with her inflammatory response.
I'd also make sure that she had appropriate pain control with a multimodal strategy. And I would aim for early anterior nutrition. So that would either be PO if she could tolerate it or via a nasocastric tube. Now, I suspect that her fever and her leukocytosis are from the pancreatitis, but I would also panculture her to ensure that there's no other source of infection. Perfect. That's actually exactly what I was going to ask you about.
So we start with the supportive management. She maintains her pressure with your resuscitation and her temperature improves. She does get intubated for increasing oxygen requirements, likely due to third spacing and splinting. A few days go by and she starts having fevers again and you get called. Okay, well, I would...
Certainly review everything. I mean, assuming that her previous cultures didn't grow anything, I would repeat her cultures. And I probably repeat her CT at this time as well to see if we can find a reason for why she's deteriorating. Great. So the CT shows necrotizing pancreatitis with an even greater area of inflammatory change than initial. There are no abscesses or locules of air in the necrotizing portion of the pancreas.
Your cultures all come back negative over the next day or so, so you feel comfortable continuing supportive management. Unfortunately, she becomes increasingly distended and difficult to ventilate. So while in the setting of increasing distention and now difficulty with ventilation, I do start to worry about the dreaded abdominal compartment syndrome.
So, of course, I'd start by examining her and getting a bladder pressure. Now, since abdominal compartment syndrome is not just diagnosed by bladder pressure, I'd be looking for additional signs of end organ dysfunction, like oliguria, and he wanted to have a compromise. All right, so when you go see this patient, you find her abdomen somewhat tight, and the bladder pressure comes back at 20 millimeters of mercury. But she is still actually voiding quite well. So ICU further sedates the patient.
and they add a paralytic, and their follow-up bladder pressure shows a drop in the intra-abdominal pressure to 12, and they do see some improvements in ventilation. Hmm. So I think I would monitor this patient pretty closely given the concern for impending compartment syndrome. If she doesn't respond to deep sedation and a paralytic and has ongoing difficulty ventilating or an increasing bladder pressure.
or new findings of end organ dysfunction, I would probably be moving ahead with a decompressive laparotomy. So she does get worse and you do take her for a laparotomy. Would you do anything else in this operation? So I think this is the real take home point here for me. So as tempting as it is to go after that necrotic tissue and that pancreas early.
It's not what we came here for, and I don't want to risk introducing further infection, cause bleeding, worsening the existing inflammatory cascade. So I would decompress the abdomen, look for any other intra-abdominal complications over pancreatitis, like any... bowel issues, but I would not mess with the pancreas. Yeah, I think that was the very first piece of surgical advice that I ever received.
So yeah, I would try not to mess with the pancreas. I would observe her for 24 to 48 hours. Of course, that's going to be dictated by her clinical status. And then I plan to take her back for a washout and hopefully a closure when she's improving.
If she's worsening, I would take her back sooner to do a washout. And I think at that point, you really have to look for any further complications. So just like you were saying, Jordan, is there any evidence of bowel ischemia or something else that's affecting her status? On that note, she drops her pressure sometime before you plan to bring her back.
You go to assessor and examine her abdomen and the temporary abdominal closure device, and there's blood leaking all around the dressing, and her abdomen is more distended, and the section's all clogged with blood clots. Ugh, I dread this. We have to ask ourselves if we think this is likely to be a bleed from the operation itself, or really what I'm worried about has she developed a pseudoaneurysm secondary to the pancreatitis. A pseudoaneurysm in the mass of an inflamed...
pancreas, and retroperitoneum is going to be near impossible to control operatively. So assuming this is likely the cause, I'd range for her to get a CT angiogram followed by embolization by interventional radiology.
Yeah, I totally agree. Assuming that we're quite confident that the likelihood of this being a bleed secondary to the operative procedure itself, I would do the exact same. So in this case, she's found to have a splenic artery pseudoaneurysm, and I are thankfully able to embolize it.
You end up taking her back to the OR later for the planned washout after about six hours when she's nice and settled and you evacuate some hematoma and then you end up doing another temporary closure. Wow, this patient really can't.
catch a break i'm starting to suspect this is going to be a long course for her so you know i think as she goes back to the icu we have to really continue to be vigilant for further complications definitely those patients going to be in the icu for weeks if not longer
And it's going to take her months to recover if she even survives all of this. Yeah, we have to be cautious and patient with these patients. But we know they can recover. These complications we discussed are rare but important to recognize early. Patients can also develop colon or bowel perforations or ischemia, as we alluded to, secondary pancreatitis. They can also develop endoputaneous fistulas, especially after operative intervention is required for these other reasons.
Yeah, so again, it's really important to support the patients, support their family and help to set their expectations early. It's often a tumultuous course, but that doesn't mean that they're not going to recover eventually. It just means that we need to be very clear about what their potential course is going to look like.
Along those lines, though, talking about goals of care is a very important aspect of this, and you have to also continuously reassess that as their course unfolds and their likely outcomes become a little bit more clear. And of course, it's important to support the patients and their families emotionally as needed through this process because it can be quite difficult and very frustrating for them.
All right. So because I'm the newest member of this team, I have been granted the honor of hosting our game for today. Thank you very much. In particular, Jordan, for allowing me this privilege. So today's game is called pancreatitis is hard. Should we do a VARD? What do we all think of that? What about can't eat no more? Let's do a pistou. That's brilliant. We could do that too.
Any other thoughts about how great this title is? The title's great. I was, I don't know. My thought was pain won't go away. Is it time for a fray? Oh, wow. That one's really good. Okay. Well. I'm going to stick to pancreatitis is hard. Let's do a VARD. And these are your options. You're going to get clinical scenarios. And the options to move ahead in any of these clinical scenarios is antibiotics, skin, drain, more drain.
barred, operate, or do nothing. What you're saying is we pretty much have every option. Basically. Okay, so let's start with case number one. We have... 58-year-old male, first admission with alcoholic pancreatitis on post-mission day three, has a white count of 16 and a new fever on the ward. Who wants to go first?
Well, I can take a stab at this one. It's such an honor to be able to get to give answers in the game. I really feel like I've graduated. I hope I can give good ones. So for this patient, I mean...
This is not out of keeping with what we would expect for the course of pancreatitis if somehow this patient hadn't been imaged on admission, which is rare in... uh my hospital then i probably would image them but i think really at this point i wouldn't do a whole lot other than make sure that i was appropriately resuscitating them and i was treating their pain and that i was giving them some enteral nutrition
I think it's really important to communicate to the whole team that's going to be looking after this patient that they are going to fever and they are going to intermittently have an elevated white blood cell count just to make sure that everybody's expectations are that those things are within keeping of their clinical course. But I wouldn't do anything more than that.
this point. Okay Jordan do you want to add anything to that? Yeah so I agree and in particular without a clear clinical indication I would avoid giving antibiotics in these patients until we have some clear indication of what we're actually treating. as long as the patient's relatively well. We find antibiotics get thrown at these fevers all the time, and they're not without harm when they're given unnecessarily. Okay, great, great. And Ashley, any final comments on this one?
Yeah, I agree with the other comments. I mean, really just back to basics, examining the patient, making sure we're not missing any signs of infection, and then hand culture. Okay. The next case is a 67-year-old female with severe gallstone pancreatitis, initially improving in the ICU. Post-admission date 35, sudden large volume upper GI bleed, and she undergoes endoscopy, shows blood from the ampulla that cannot be controlled. Jordan.
This sounds like the classic hemococcus pancreaticus. So, of course, you're going to resuscitate this patient. But ultimately, your hope is to not get quagmired in an impossible OR with this patient. You're going to try to get them to interventional eventually for embolization. Whether or not that includes a CTA beforehand depends a little bit on the clinical situation and on your radiology colleagues. Perfect. All right, next case.
32-year-old male with severe pancreatitis after a scorpion bite while backpacking in Argentina. Post admission day 14, you've got persisting vomiting. Scan shows gastric outlet obstruction from a large retroperitoneal collection. Graham, what do you want to do? Of course, we worked in a case with a scorpion bite, so I think this would be a great case to talk about in a multidisciplinary setting.
14 days is pretty early, so I can't imagine people are going to be too excited to intervene on that collection. I think at this point, the priority is really being able to get some internal nutrition into this patient, so I'd probably advocate for a nasal... a jejunal feeding tube if we could get that from our colleagues. If not, some TPN, good pain management and fluid management, and we'll continue to watch the collection. Ashley, do you have anything to add?
Yeah, I agree. Decompressing with an NG and feeding with an NJ if we can, but really trying to kind of buy your time until hopefully and ultimately once it's been more well formed, then we could consider an endoscopic approach to drinking. through the transgastric. What about you, Jordan? Any desire to drain this and maybe relieve some of that obstruction? No, I agree with what's been said, but I refuse to answer further based on the nature of this question alone.
All right, all right. How about this one then? 82-year-old female with necrotizing pancreatitis and multi-organ failure intubated in the ICU on three pressers. Jordan. Yeah, so certainly in a patient this sick, you're going to be looking for potential causes for this type of decompensation.
you're going to resuscitate the patient. I think when they're this unwell, I would be willing to start them on empiric antibiotics, of course, until we figure out exactly what's going on. And then likely I would want to try to get this patient stable enough to scan them to try to...
to get some sort of definitive diagnosis before diving into any type of intervention. And I think it also goes without saying that in a patient who is, you know, advanced in age, potentially has additional comorbidities, frailty, etc. in a very... high risk situation, we'd want to be having discussions with the family, discussion goals of care as appropriate here too. Okay, great point. Anything you want to add to that, Graham?
No, I mean, I totally agree. I mean, this is a very risky situation. This patient's mortality is extremely high. And yeah, I mean, I think good communication with the family in this setting is so important. Okay, great. All right, for our last case, Ashley, you can... take it away it's a 37 year old female with necrotizing pancreatitis on urtapenem and she has a single 12 french retroperitoneal drain in unable to tolerate any oral feeds and she's been having inter
intermittent fevers what do you want to do feels like i'm taking over a service so i'm gonna review what's happened and get the information from the team i'd see kind of where we are in the course when the last imaging was what we have done or tried already for nutritional status and so if she's just And PO feeds, I would then be looking at an NG or an NJ for an attempt at enteral feeding. And then if it hasn't had a recent scan, I would rescan.
to see what is happening at this point in terms of the fevers and if we need to do any further interventions such as further drainage, upsizing the drain or other kind of percutaneous or endoscopic procedures to try and control any infected localizing tissue.
Okay. Anything to add to that, Jordan? No, I don't think so. I think this kind of question where we have a patient who has necrotizing pancreatitis and a retroperic needle drain in... it's really dependent as ashley said on kind of like what stage of the patient's course you're in what the plan was with that drain
what type of underlying collections and necrosis you have to deal with. So again, I think this requires a review of everything that's gone on with the patient, what the existing plan is, what imaging has been done, what their clinical status is. And I think based on all...
those and multidisciplinary discussion to come up with a flag for the patient. Awesome. Sounds good. So that is the last case for pancreatitis is hard. Wait, you didn't ask me. You didn't ask me. I just take out their gallbladder. Okay. Okay, with that note, that is the actual conclusion to pancreatitis is hard. Should we do a VARD? Thank you all very much for your thoughtful answers.
And for a great discussion today, that was really interesting. Winner is not Graham today. Everybody else is a winner except Graham. But the actual winner today is Dr. Jordan Nada and not Graham. I'll take the win, and everyone out there, dominate the day.
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