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Hi, everyone. Thank you so much for coming to meddles. Talk on pancreatitis. It's lovely to see you all here. Um, and I'd like to introduce our speaker. Um, if you want to go ahead and introduce yourself, puzzle, hello, everyone. Um, my name is, uh Mister Basil Abraham. I'm one of the senior surgical registrars working in the Department of Surgery in Manchester, United Kingdom. I'm not sure if I can see everyone, but I'm sure you there. Um, our today's talk, I've been invited to talk to you about pancreatitis. Um, so feel free to ask any questions, add any commands in the chart box. Meanwhile, don't be shy. This is how we learn. I'll try and have a look on the chat box every now and then. Ok. Right. So pancreatitis, um, in order to talk about the pancreatitis, which I think is a, is, is a really important topic. Um, and uh, uh it's a, a not uncommon presentation that you will encounter in your medical practice. Um, either you are a medical doctor, a surgical doctor or a GP. Uh, we're gonna touch base on some of the basics about the pancreas and the acute and chronic pancreatitis, the level of which will be on um a basic level. First, I think we're gonna just um touch base for our medical students and then you're gonna go a bit more advanced on the um other modalities in treatment of Panis and the most recent guidelines um that could be helpful in your uh managing patients very good. So, the learning objective of this talk and by the end of um today's presentation, you should be able to diagnose bronchitis swiftly and diag distinguish between its acute and chronic presentations using the clinical symptoms and diagnostic tests. Um The other thing you should be able to is to construct anne management plan for a patient presenting to your department um with pancreatitis. Um we should also be able to identify and address the underlying causes and ecology of panis as well as monitor and manage and prevent the potential complications of panis, which are really important to know. Um And most importantly, you should be able to collaborate um with all relevant specialities in your multidisciplinary approach to coordinate the care for patients presenting with bronchitis, right? So, starting um pancreas um as you all know, um it is an accessory organ, um both exocrine and endocrine functions are found to be in the pancreas. It's located in the retroperitoneal space. Um and it's have, it has five parts um and has both external and internal components um touching base on the anatomy. Um So it it, it is supplied by arteries and nerves and find things like any other organ. Um So it is supplied by the splenic artery um and the pancreat artery, gastroduodenal and sma or the superior artery um innervated by uh both parasympathetic and sympathetic nerve plexus. The parasympathetic as uh of all the uh of most of the uh organs in the abdomen is by the vagus nerve. The sympathetic plexus is by the pancreatico splenic and pyloric um uh nervous system. And it's uh drained by the pyloric lymph nodes and the pancreatic splenic uh lymph node system. Um As we said, uh previously, it has external parts and internal parts, the um external parts, it has five components. So you have the um the head, the ate process, the neck, the body and the tail. As you can see in the picture, um it does have a duct system um that drains all the um hormones and the relative uh enzymes secreted and drains the enzymes mainly from the pancreas, the the digestive system through the main pancreatic duct of weu and the accessory pancreatic duct. So we're not gonna go into much details on the annoy. Uh but these are the most relevant things that you need to know uh to understand um the concept of pancreatitis and how we treat it. The functions of the pancreas. It has two functions, as we said, um endocrine function which involves hormonal regulation um by releasing the insulin glucagon and somatostatin from the corresponding B cells, alpha cells and delta cells. The exocrine uh function is um mainly releasing a couple of um uh pepto das is lipase nuclease and amylase. So, these are the digested um uh enzymes helps in digestion. Mainly. Um the most two important um enzymes we need to know about are the amylase and lipase which will help you as a diagnostic marker, diagnosing pancreatitis. Um And it's also important to know that amylase is also found in other organs. Um like salivary glands, small intestine adipose, tissue, ovaries and the muscles, mainly the skeletal muscles. Um two major forms of amylase are found also. But um when you do blood tests, the pancreatic cancer delivery gland amylase. Um and it's mainly responsible for digestion of starch. Um and oligosaccharides uh by hydrolysis, right. So, moving forward to pancreatitis. Um so there are some definitions um for acute, chronic and acute and chronic. These are the three main um conditions that you will encounter in your in your medical practice. So, acute pancreatitis mainly is a sudden inflammation of the pancreas, as you can imagine, which may be associated with a systematic inflammatory response, um which can impair the function of other organs or systems. A chronic pancreatitis such as a chronic condition which involves progressive inflammation of the pancreas, which fails to improve over time, resulting in permanent damage to the structure of the pancreas and hence to its function as well. Um acute on chronic as it says. So it's acute exacerbation um of the pancreas on top of the chronic pancreatitis that is already um already there. So, uh the major component of our discussion today, our topic today is going to be on the acute pancreatitis um because it's um it's, it's, it's most common um presentation and it got um a significant comorbidity and um risk of major complications that you need to be aware of. So, to classify um acute pancreatitis, this is according to the um the most recent Atlanta classification, the revised one of 2012. So you can classify acute pancarditis according to the face according to the severity or according to the type. So according to the phase, it can be classified as early acute bronchitis or late according to the severity, either mild, moderate or severe. And according to the types of the um uh complications, it can be edematous or necrotizing acute pancreatitis to um further elaborate on this. Um So this is just a summary um of, of the Atlantic classification. As we said, the early, um the two phases are early and late. So the early phase involve the first week after the onset with the disease manifesting as a systematic um inflammatory response, whether the late phase, um it generally occurs in the second week and can persist for few weeks and even months. The late phase is mainly seen in the moderate and severe forms of acute panis. Um if you classify it according to the severity, um it's either mild, which involves no organ failure and, and no local or systematic complications and it usually resolves within the first week. So this is mainly the intersil edematous pancreatitis. Um uh On the other hand, the moderate um severe acute bronchitis is uh involving a transient organ failure, um which identified as less than 48 hours. And it does also involve a transient local complications and exacerbation of comorbid diseases. The severe form um involves a persistent organ failure for more than 48 hours. So the moderate and the severe normally involves the necrotizing panis. Um And that brings us to the morphological classification of acute panis. It's either acute edematous inters pancreatitis or acute necrotizing pan colitis. So you're gonna encounter um these kind of um classification, these um naming of acute puc tires in the following few slides. So, um I will just leave it maybe for a few seconds. So they can have a look on the phases severity and the morphology. Ok. Um So that brings us to what, what causes panis. Um So feel free to comment on the chat box. Um What do you think could be the cause of panis? There are plenty and plenty of causes but common is common, there are some on the pictures. So you can see um alcohol exactly excellent. So alcohol and gallstones. Um So the two main causes for acute panis are alcohol and gallstones. The two of them account for nearly 80% of the causes of acute panis. There are some other forms um of pathologies that can lead to acute panis and that bring brings us to the famous um phrase of I get smashed. Um So there are some other causes that you need to be aware of. But as we said, uh nearly 80% of the presentations of acute pancarditis are caused by other gallstones or alcohol. I can see some other ment as well. Exactly. So post ercp idiopathic alcohol, gallstones, alcohol and gallstones, gallstones, idiopathic. Exactly. So, um, it can be idiopathic um, gallstones, um, alcohol trauma, um, steroids, mum's autoimmune scorpion sting. It depends where, what, what, what part of the world you at, um, hyperlipidemia, hypercalcemia, endocrine. Um, the ERCP basically, which is, um, as you all know, is an endoscopic reto grade cholangiopancreatography and drugs. So, idiopathic, um, just touch base on the idiopathic uh form. Um, because sometimes it's just over, um, over diagnosed. Um, what is it defined as is pancreatitis with no etiology established, but you need to establish this after all the investigations to rule out other causes. Um, so ideally you should have at least two ultrasound scans to rule out gallstones and, or an MRI scan or MRC P to rule out um, other forms of pathologies including small gallstones and a found ultrasound. Um, sometimes microlithiasis like um small, um, sand grains of stones that you can see on the scans that can be tested by endoscopic ultrasound or es. Um And you've tested your um lipid uh profile, you've tested your calcium level. There's no other thing that you could account for acute bronchitis. Then you can diagnose idiopathic acute pancreatitis. Um Also the uh autoimmune is um something that you need to consider as well by testing what it's called uh ID DG four. So as we said, um the uh gallstones and alcohol accounts for 80% of the causes. So you need to be um you need to be aware of this. So how do patients present with acute pancarditis? So they present with pain, um, abdominal pain which is sudden onset. Um As you all know, when you assess the pain, you need to uh go through all the um all the characteristics of the pain by the famous um mes of SOS. So the site of the pain is normally epigastric can be central, um per it can be generalized. The onset of the pain is of a sudden nature. Um The character of the pain is, it's, it's mainly a gripping severe pain that radiates to the back. Um Most of the time it radiates through, um sometimes it just radiates around like a belt. The timing of the pain is just, it's still an onset, as we said, um it's relieved by leaning forward, which is basically due to the uh position of the pancreas in the retroperitoneal space, patients do have nausea and vomiting as well. When you examine them, you will have tenderness in the vi gastrium or generalized tenderness in the abdomen and sometimes some localized gardening as well. The bases are normally um and well, um with um abnormality in their vital signs. So they could have um tachycardia hypertension. Um and sometimes they could develop some fever as well. So it's a wide variety of presentation. But I think if you focus on the nature of the pain, you assess the pain correctly and you examine the patient coupled with obviously your um investigation. So you would reach the diagnosis of pancreatitis. However, you also need to um think about other conditions that could present similarly um as the pancreatitis uh which brings us to the differential. So if you um also just right in the chat box, what do you think could be the differentials for someone presenting with acute onset of epigastric or central abdominal pain with nausea and vomiting because these, these symptoms can be due to um some other conditions as well, which are really important. So just have a have a quick thinking about it. What do you think could be the differentials? Good. We're seeing some responses. So, cholecystitis GERD correct. So you could have um cholecystitis which can present with epigastric pain. Um sometimes it's more into the right upper quadrant, but yes, um Gastros reflux disease, um it can present with epigastric pain as well. The, the, the less severe, I think, um, but severe gastritis as well mi in elderly, that's really important. Exactly. So, if you have got someone who's diabetic and presenting with a gastric pain, um, if they have inferior MRI, they can present with a gastric, um, with epigastric pain. So, you need to make sure that this is not an MRI that you can miss, uh, which can be disastrous in, in sick patients, peptic complications. Um Exactly. So someone with a big gastric pain, severe tenderness unwell. Yes, it can be pancreatitis and you know, the patient most likely is going to be present pancreatitis. But you need to do, you need to rule out perforated peptic ulcer. Um So if someone's got air under the diaphragm on their x-ray, so your, your, your, your management is completely different now. So you, you need to act um, accordingly. Um So, yes, exactly. I think you've mentioned most of the things AAA. Um Yes. So it can be, um, if someone's got, um, abdominal pain with, um, a history of AAA, um someone's vasculopath, yes, it can be as well. Acute obstruction, agreed. Um, if someone's got, um, especially small bowel obstruction, um, you have that pain. However, in the end, the obstruction, you will have, I think abdominal distension and the uh, absolute constipation as well. So, um, good thinking is. So I think we've covered most of the differentials. Um, so the most important things I needed to talk about is the MRI and the peripheral ulcer. Um and the AAA. Um So these are things that you, you need to also think about and they're all emergencies. So that's why we need to bring it out. Ok. So to diagnose pancreatitis, um you need two of the three of these criteria. This is according to the Atlanta guidelines. So you need to have abdominal pain consistent with the disease. As we described the pain earlier, you need to have an evidence of pancreatitis in your blood tests, which are malaise and or lipase depends on where you are. Depends what modality of um of testing you do um in your local department or in your hospital, um amylase or lipase, they need to be more than three times upper limit of normal in order to see to say that yes, this is a um a panis um and all characteristic findings from the abdominal imaging. We don't normally do imaging for pancreatitis, but I will, I will just walk you through. What are the indications and why we do them later. Um The only imaging you need to do first is x-ray, as we said, chest x-ray. So if you have two of these three things, abdominal pain, biochemical evidence of bi pancreatitis and the findings on your abdominal imaging, you have two of the three, then you can say this is most likely is pancreatitis. So we're going to manage that look for the causes and um, see what we can do for the patient. So you've taken history, um, you've examined the patients, you've diagnosed, you ruled out other important uh differential diagnoses and you, now you've diagnosed the patient with acute pancreatitis. So, what are the tests that you're going to do? Um, so these are some of the tests that they're normally done. So you need to do a blood gas, um, which is quite quick. Um So you need to know your ph level, you need to know your basic tests. Um You need to know your lactate level. Um You need to know the um the the bicarb level. So normally in acute severe pancreatitis, patients can be um can be acidotic, they can have a high lactate as well um because they're severely dehydrated. Um and they can also have a high basic success as you can imagine. Um if they develop respiratory complications, they can have um type one involving to type two respiratory failure. So you need to do like you can, you can find out a lot from the guys. Um and that can help you to identify where this patient should be treated at and what level of care this patient should have. Um You will do your full blood count or complete blood count depending on where you are. So you check your hemoglobin levels. Um It can be, it can be very, very low in hemorrhagic pancreatitis. Um you'll check your white cell count, it can be high. Um You'll check your platelets level and other modalities of your full blood count. Um your CRP level, which is an inflammatory um response indicator, it will be high and that's really important because one of the scoring system modalities identify that if the CRP is more than 150 that it's on its own as an indicator for poor prognosis and severe pancreatitis. The CRP is also important. Um You'll need to do urea and electrolytes or renal function test depends on what you call it. Um And um urea can be very high, especially in someone who is um dehydrated and losing fluid in pancreatitis. Your creatinine level can be very high as well. Um If you developed um some renal complications. So this is your first assessment of organ failure in acute pancreatitis is the urea and electrolytes. You need to check your potassium, your sodium, your other electrolytes level as well. So you might need to replace them liver function tests. Um So obviously, the pancreas is in close proximity to the, to the biliary system and to the liver. So you will be affected. So your, your, your liver enzymes like your alt, your LP, um they, they can be, they can be deed as well. Um More importantly, I think you need to check your albumin level because um there will be um album aia in the treatment in patients with pancreatitis and that can help you score the score, the severity of pancreatitis as well. Um Coagulation profile, I don't know if you normally routinely do it, but if you're suspecting um a severe pancreatitis that can help you um identify if this patient is going for multiorgan failure and having um uh DC. Basically, um it's important also if someone who is comorbid and he's on anticoagulation, um medications like um uh dual anticoagulation medications or like Warfarin. So when you do your coagulation profile that will guide you, um either you need to replace or give on any other medications to alter the levels of your um coagulation profile, especially if you're planning to do a procedure um to relieve um uh the causes for pancreatitis bone profile. This is part of your um assessment as well. So mainly you look on the calcium, basically see if you've got any um uh any hypercalcemia or hypocalcemia um in patients with pancreatitis. What do you think happens to the calcium? Is it increased? Is it decreased? And why? So mainly in five, what we do is we check your calcium, the magnesium, the phosphate. Uh So there's a couple other things that you need to check. Yes. So it does decrease and do you know why? So, interestingly, um pancreatitis does cause hypercalcemia, but if you have high calcium hypercalcemia, it can on its own can cause pancreatitis. Exactly. Excellent. So this is the, the term that we're looking to into the uses for saponification. Um So it's part of the inflammatory process of the pancreas that it causes saponification of the fat in your body. And then that requires the calcium. So it depletes the calcium level and hence that you have hypercalcemia. Excellent. Um All right. So you've done your blood tests, some other blood tests that you might need to do not acutely, but maybe on a later stage is the lipid profile. Like if you couldn't find any cause for the uh pancreatitis, then you, you do your lipid profile just to check your triglycerides. And there's a cut off point for triglycerides and the Atlanta and Atlanta uh guidelines. You need to have a look on that as well. Sometimes as we said, if you couldn't find the cause for pancreatitis, you've out controlled your gallstones, you've out control your alcohol. Uh the patient is not alcoholic, the lipid profile is fine, the calcium is OK. Um And you've done the testing, all the tests, you've done a couple of ultrasounds, you've done the MRI scan, you've done even done the endoscopic ultrasound, you couldn't find the cause. Then you, I think you, you can do for autoimmune causes, especially the patients who got autoimmune diseases by checking IgG four. OK. So these are the two biomarkers. Basically, we normally use um in diagnosing pancreatitis. So these are both malas and lipase. It depends on where you are. It depends on your department. Um it depends on the availability and the resources basically. Um But what you need to know, I think most importantly is when does the amylase and the lipase start to rise? When do they reach the peak? And how long do they stay in your blood test? Because if you have, if you got a patient with pancreatitis, presenting to your emergency department, you've seen the patient um and uh the pain started two hours ago or the pain started seven days ago. That makes a huge difference because you might have normal amylase and normal lipase. And in these situations, then you might need to do a scan. So mainly serum pancreatic enzyme as amylase lipase measurement is the gold standard for diagnosing acute pancreatitis. Um and an episode of acute pancreatitis, amylase lipase and other enzymes like elastase and trypsin are related into the blood stream at the same time. But the clearance of these enzymes varies depending on the timing of the blood sampling. So, as we said before, amylase is mainly an enzyme which is secreted by the pancreas, which aids in the digestion or starch. Um it does start to rise within the 1st 6 to 24 hours. So it started to rise between 6 to 24 hours. Um It peaks at 48 hours and return to normal over 3 to 7 days from, from, from day three. Then you'll see a significant drop in in amylase level. And that's why we don't normally repeat the test. So you just need one diagnostic test of amylase and lipase and you don't normally need to repeat it because it has no um no added value at all lipase. On the other hand, um which is another enzyme secreted by the pancreas, um which normally aids in the breakdown of the triglycerides. And it is considered a, a more reliable diagnostic marker for acute, for acute uh pancreatitis. Um It does have a higher sensitivity and a larger diagnostic window. Um compared to the Malays, there is a uh Cochran review has shown the sensitivity of MLS and lipase around 72 and 79%. So, the sensitivity of MLA is 72% while the lipase is 79%. Um However, no laboratory test is consistently accurate to predict the severity in patients of pancreatitis. So, I don't think um the level like how much of MLA is and how much of lipase you will find like if you found MLA of 400 or if you find MS of um 2000. Um I don't think that will be relevant in you saying, oh, this is a severe pancreatitis or this is um a mild pancreatitis. You just need more than three times um the level of um normal to just to diagnose and it's only one test, you don't need to repeat it and it will not um help you identify that this is severe or not. What to take out from the slider. Thing is to look on the timings. Um, each of the biomarkers started to rise when it peaks and how long does it stay in your body lipase is slightly better? Um, 79% sensitivity compared to 72% in MS. So, we've done your blood tests. Um, you're diagnosed or now you're not, you're not sure. Then you, the next step is to do some imaging. As we said, first, we've done an x-ray um just to rule out perforation or basal pneumonia, um or other causes the other imaging modality that you can do for diagnosing acute bronchitis is CT scan. Now, these images are of a patient who presented with acute severe gastric pain, which is very suggestive of acute pancreatitis. However, the malaise was normal um within the normal limits. Um A this is a contrast enhanced CT scan, which was performed. So the findings are um you can see there's some edema. So most of the pancreas is mainly normal. On the first slide, on the top, most of the pancreas is normal. Um And there's on the second slide in the middle, there's some edema of the an process which is the blue arrow. And on the bottom slide, there's some edema in the peripancreatic fat, uh which is the yellow arrow. So if you see that haziness that's grayish kind of color around the pancreas. This is the what we call a stranding of fat around the pancreas. This is consistent mainly with interstitial pancreatitis. So you have a normal looking pancreas on the top in the middle, you have a um some edema around the aid process and on the on the bottom you have stranding of the peripancreatic tissue. So that means you have, this is probably a mild acute interstitial um uh pancreatitis. Um Maria, let me know when you have that presentation up from your side. Yes, it's just worked. Now, I should be able to put it on. Is that all right? I didn't mean to interrupt you. No, that's fine. I'll just do it right now. So that CT was done because um we have someone with clinically, we're suspecting is acute pancreatitis. We've done the blood tests, we've done the amylase and the lipase, um which was normal, both were normal or whatever you have. Um They were normal now to rule out other modalities or to diagnose the other criteria as you, if you remember is the C the imaging with the CT scan and that showed acute intersession pancreatitis. Now, we can treat pancreatitis just getting it up. Now, it's um it's in my power point. I just need to change it into PDF slides myself. Oh, I see. I think I'll just share screen just to avoid the weight because I, I don't know why my laptop's being really slow. Yeah. Normally tech problems happens when you need them. Right. Let's bring it to. So, I think you're on slide 19. Perfect. I'll just find that slide now and present. There we go. Yes. So I'll just go on to the next one then for you. Yeah, let's go next. Um So other imaging modalities, as we said, um we can do, we are doing x-rays. You've done a CT scan just to aid your diagnosis rule out other things. But on admission, the the etiology of the cause of acute bronchitis should be determined that helps guiding the treatment and minimize recurrence um of the disease. A transabdominal ultrasound should be used to determine the presence of gallstones um when doubt exists about the diagnosis, then a contrast enhanced CT scan provides a good evidence um for the presence or the absence of pancreatitis. Um optimal timing for performing A CT is basically 72 to 96 hours. If performed earlier, then necrotic or ischemic changes might not be seen. So, as we said before, the pancreatitis can develop into necrotic pancreatitis, but it normally happens after within like after day three. So if you, if you don't see the scan initially to aid your diagnosis, that you're not quite sure you're looking for other pathologies that could be the cause of this. Um Because you, you didn't have two of the three of the um criteria and then that's fine. But if you have someone with, with like with pain and uh very raised anal laser lipase, um and then you've diagnosed pan artis, your CT scan should be within 3 to 4 days. Um And that only just to see if there's any deterioration, um or if there's any complications, patients with mild acute pancreatitis do not need a CT scan um in the majority, in the majority of the cases and only need to be performed if there's a deterioration in their clinical status. So, if someone's with mild pancreatitis, um but then they develop some organ failure or some complications, they're not progressing. Well, you're not happy with them, then that's fine. You can do a CT scan. But the reason here is because you're looking for a complication of, of panis. Um The vast majority of complications in patients with um acute pancreatitis can be suspected by um laboratory tests. Follow up scans in severe pancreatitis are recommended again if clinical status deteriorates and the patients fails to improve. Um Next MRI is preferable to CT scans in patients with contrast allergies. Uh patients with renal impairment or patients who are young or pregnant in order to minimize radiation exposure. Um It's, it's less sensitive than the CT scan in detecting gau in the fluid. Um No, where no ethology has been identified and where ultrasound scan showed um no gallstones. An MRI, an MRC P which is a type of MRI um or endoscopic ultrasound should be performed rather than ERCP in the absence of the range of left. So if, if someone's got REIS and you show this is obstructive um stone that's causing pancreatitis and that's why you can do ERCP because you're aiming to do an intervention after that. But for diagnosis only um MRI can be helpful um coupled with S if, if you're, if you can't find the cause, as we said, and you're looking for small stones, I will see on the scan. Yeah. Next. Now we have obtained diagnosis of panis. We need to score the, the severity of panzer. Probably the there are some several scoring systems have been developed to, to to predict the severe acute pancreatitis, but evidence on their predictive performance is quite variable. Um Currently, there is no systematic review that we could found. Um has it concluded all the studies assessing the accuracy of the diff different clinical scoring systems um which used to predict the severity and mortality in people with acute bronchitis. There are several scoring systems. Um I think that the first three are the the ones that I've seen people doing. Um Branson criteria, Glasco in risk score, um acute histology or Apache two. Basically. Um some people also do use CT severity index. So these are scoring system to see how like you you can say, oh, this is severe pancreatitis or this is mild or moderate. It will help you to identify where the patient should go. Basically, are you happy with them to stay in the ward? Are you happy? You should be on level two or level three. Next. No, we've, we've diagnosed pan artis, we've um done our tests, we've done our imaging. Um We've scored the severity of it. We identified where this pain should be, how we would manage. Um I think the first thing that we need you all to know and to take out from this presentation is you always start by ABC D. So you always assess the patient as a whole. You're not treating the pathology only you're treating the patient. So you check your airway, check your breathing, correct any abnormalities, circulation, um um disability and exposure. Basically, you do your ABCD always fluids and fluids. So uh pancreatitis patients do lose a lot of fluids that you can't see. So in thirds, they have a lot of third space loss. Um but you need to be guided by other things. So you need, you don't need to overstate. So I think I have um a question, pediatric patients. Can they get, yes, they can get panis. But for the, they're not as um not for the same. Obviously, you're not expecting some alcohol to be cause of pancreatitis. But you know, some people do have um gallstones, they can develop pancreatitis. So, pancreatitis is a uh is a pathology in Petric patients. They're not as common as adults. Um and they do have um also some approach but basics are the basics. So you need to treat the patients as um as a whole as we said, um So you start with the ABC DE, um you start with your fluids. Um pain is a major issue in Panis. So you need to focus on your analgesia. Um Early nutrition is important in pancreatitis because they lose a lot of energy and it's quite significant inflammation. So they lose a lot of energy. So you need to make their, are properly, have their, they have sufficient nutrition. They might require organ support. As we said, severe pancreatitis, they have organ failure, so they might require organ support. Your management should be as a part of a multidisciplinary team. So you will be talking to several departments. You'll be talking to the emergency department, you'll be talking to the surgeons, you'll be talking to the medical doctors, intensive care doctors, radiology doctors, you'll be talking to the pain team, you'll be talking to microbiology, doctors, you'll be talking to he surgeons, you'll be talking to a lot of people. If you're treating severe pancreatitis, it obviously depending on, depending on the resources that you have in your, in your, in your, in your place. Um And, and finally, you need to treat the cause. So if it's, if it's gallstones, you need to remove the gallbladder. So these are the concepts of managing pancreatitis. Um Next. So in most uh patients, the disease takes mild course um where moderate fluid resuscitation, management of pain and nausea and early oral oral feeding result in rapid clinical improvement, fluid resuscitation should be adjusted to account for the patient's age, weight and preexisting medical conditions. It, it, in the past, I think in the past it's been, um, um, it's been a different practice of um, giving fluids and fluids and fluids giving you about like more than six liters. This is not always applicable. You've got someone who is really frail old, have conditions of heart failure or renal failure. Um, you can't be giving them like eight liters a day. So you basically drown them. So you need to be guided by their age, their weight, their urine output. Um There the you know, other things that could help you um guide your IV fluids management. Early fluid suss is imperative though to optimize tissue perfusion targets. Um prior to hemodynamic worsening, the enteral feeding should also be encouraged. Um as it maintains the gut mucosal barrier, that's um normally prevent the translocation of, of bacteria. So you need to keep your bowels active um by just early giving them early oral oral feeding even though with the NJ, sometimes like with nasal feeding. So you might need to give them small amounts of feeding so that they can keep their normal flora in, in the um in the gut. Next, in 20 to 30% of the cases, patients may develop moderate to severe pancreatitis. So about 20% maybe up to 30% they might develop to moderate to severe with an associated mortality rate, reaching up to 35 some studies have mentioned it up up to 40%. So they have a high mortality if they went to severe pancreatitis. So, thus, the it's important to diagnose an episode of severe acute pancreatitis early um who are at high risk developing complications. These patients require continuous vital sign monitoring in a high dependency unit. Um setting um if organ dysfunction occurs, obviously resistant organ failure, despite adequate fluid ation, this warrants and uh intensive care unit admission. So we need to know exactly where the patient is um is gonna be managed at antibiotics. So, if you have infected acute pancreatitis, you can give antibiotics. However, there is no role of giving antibiotics with a patient with, with intersession or mild pancreatitis. So, uh the diagnosis of infected panas itself is challenging due to the clinical picture that cannot be distinguished between infectious complications or from inflammatory status, which is caused by acute pancreatitis. The presence of gauze in the retroperitoneal area is considered an indication for this is could be an infect pancreatitis. Uh but it's only present in, in in small number of patients. The use of prophylactic antibiotics therapy in acute bronchitis. Um it's been a long point of controversy um but recent evidence have shown that prophylactic antibiotics in patients with acute bronchitis are not associated with significant decrease in mortality or morbidity. Um And thus, no, it is no longer recommended. Um in patients with infected necrotic pancreatitis, then you need to give antibiotics that could penetrate the pancreatic necrosis. So, not every antibiotics can penetrate the pancreatic necrosis. Um But normally you give antibiotics that could cover for gram negative and gram positive um uh mechanisms and anaerobic as well. Just a quick to on, on the antibiotics. So, aminoglycoside uh basically um they fail to penetrate into the pancreas, uh penicillins and third generation cspine. Uh they have an intermediate penetration to the pancreas. Um Only uh tazo um has effective uh has quite effective uh modality. I think the Cipro like quinolone Cipro and moxifloxacin um and venoms. Um they have a good tissue perforation. Uh but you need to be, you need to be aware of the uh ciprofloxacin um resistance basically. Um Next. So you need to have a con, as we said, continuous vital signs monitoring in high dependency care unit is needed. If there is an organ dysfunction, resistant organ dysfunction, that's an indication for ICU management. Um Air fluid resuscitation is indicated to optimize the tissue perfusion and hence, it might help you prevent the complications. Next. So, we've resuscitated the patients. Um We've given our fluids, uh we've decided to where this patient should be um treated at. Um We talk to the relevant specialist, the patient is in pain. So we need to assess the pain and treat the pain. Uh acute pancreatitis is a quite um agonizing condition. So you need to have uh an effective uh plan to treat your pain. So it's always better to do a multimodal approach. What does it mean? So it means that you need to give multiple painkillers that works differently. So, according to your bladder or pain relief, so you're not giving all the paracetamol or codeine or um or opioids on its own. You need to have a lot of um modalities, uh different modalities that the analgesia can work at. Some people do require a patient control analgesia. PC nonsteroidals are normally avoided because they, they might increase the risk of acute kidney injury and they can give them. And if the patient's got acute kidney injury due to the um due to some people also requires epidurals to control their pain. They always adhere to your local guidelines, your um or the national Global guidelines of the preoperative uh acute pain management. Um Basically, next nutrition. Um it's also important uh mild pancreatitis. You just give them enteral nutrition. Um It does decrease the risk of sepsis and organ failure. Um Severe pancreatitis, you need to resuscitate them first before starting your enteral feeding. Um either by mouth or by tube like an NJ uh NASO general tube. The parenteral nutrition should be reserved for patients who are unable to reach their goals with the naso general feeding. Um Why? Because TPN itself, the total creatin lesion has got its own complications. Um The supplementation of pancreatic enzymes. We don't normally think about this in the acute phase, but in the chronic phase, you might need to supplement the enzymes, um should be prescribed um for someone who's got exocrine insufficiency. Thanks. So, outcomes of pancreatitis, as we said, um maybe around 10% to a bit more than 10% they can have severe necrotizing pancreatitis, resulting in organ failure. And then it causes itself can be sterile, which is most of the cases and, but it can be infected. The mortality increases significantly within um within every complication happens next. Um As we said, complications, so, complications can be local or can be systematic. So something local in the pancreas. So we can have acute peripancreatic fluid collections or acute necrotic collections. Um So in mild cases like anesthesia, derma pancreatitis, um they can develop acute peripancreatic collections in severe cases like um acute necrotic collections, um they can develop later to an infected necrosis and hence their mortality will be much, much, much higher. Next. Um This is just a diagram to um to simplify the outcomes. So, basically, if you have acute pancreatitis with fluid collections, as we say, it's either interstitial or necrotizing, um you will develop in less than four weeks, acute peripancreatic collection and in more than four weeks, if it persists that could go to the cyst um in necrotizing panis um in more than four weeks, if it persists, you will develop what we call a walled off necrosis. So, there's a question about how soon would you consider starting enteral feeding via NJ. So if someone's got acute severe pancreatitis, you can't start, you can't have, um who can't have oral feeding, then you need to optimize the nutrition as soon as you resuscitate, um as soon they're stable and they can have an nasojejunal feeding, you should start. So the basically what we do normally is that we uh send a consultation to our dietician on, on the second day after we make sure that, ok, this patient is reer now, they're, they're kind of stable. Um They are supported in, in the relevant place. And then we do a dietician referral to assess the need for NJ. Feeding. Not all of them require feeding though. Um some, some, some of them can eat and drink. Can this necrosis reach the wall and spread locally. So it normally it develops a wall. After four weeks. Normally, it will be necrosis within the pancreas itself. And then you will have necrosis around the fat. And then after four weeks, you will have a wall of necrosis. Can the necrosis reach out? Yes, it can reach out. You can have um it can reach out to the vessels, it can reach out to the vessels, mainly causing thrombosis of the uh portal vein. It can reach out to the arteries, it can cause you zoo aneurysm. Um So it's all part of the inflammatory pulses of the pancreas. If you remember the anatomy, well, you will know all the local complications. Um It can reach out to the bowel as well and just cause you um uh bowel perforation and bald fistulas. Um at the end. So these image uh next space. So these images show the normally enhancing pancreas on day one. So this is day one on the, on, on the uh on the top, on the bottom. Um But the patient's condition worse and the second CT was performed on day three. Um notice how great a part of the pancreas body entail is no longer enhancing, indicating this indicating necrosis. So this is how Neco looks on a CT scan. So it was enhancing on the day one and day three. You can't, you can't identify the pancreas. Now from the fact, um next week, now this patient presented um with a gastric outer obstruction two month after an episode of, of acute pancreatitis. This is two months, more than four weeks. Um And he has a gastric outlet obstruction. What does it mean? Gastric outer obstruction means patient cannot keep anything in their stomach. So something is pressing on the stomach, something is causing the food not to go down from the stomach. Um What you can see on the left hand side is basically there is a hemo well demarcated peripancreatic collection in the lesser sac which like sits on the top of the stomach and the pancreas. Um We can't see the stomach lumen in this. Um So the this patient does not have fever. So that means they had acute um pancreatitis, which is interstitial and they have peripancreatic collections. They didn't have fever. There's no signs of infection, there's not a sepsis. So you wouldn't expect this to be an acute um uh like a necrotic collection. This is probably a zoo. The cyst on the right hand side, this was drained. We'll just show you later how is it drained next place? So this do the cyst, as we said, um as we've seen on the, in the previous slide. So it's basically a collection of the pancreatic juice. Um It occurs as a result of the interstitial pancreatitis and in the absence of necrotic tissue, um its communication between the pancreatic duct may be present. Um If it develops more than four weeks, the differential diagnosis of such a thing. Um If you go back, go, go, go on the slip back here. If you can go one slide back here. Yes. So this is um the cyst on the left side. If you look, it can be a differential for zoo aneurysm, as we said, if it eroded through the vessel or it could be due to um a cystic mass. Um But this is the cyst. Next, please. Next. Systematic complications. Uh The the main three organs that are affected by um pancreatitis are the lungs, the heart and the kidneys. So you can have respiratory failure. You can have um a um a, a cardi pulmonary failure. Basically, you have a severe hypertension, um and renal failure as well as in the form of acute kidney injury. Next. So, respiratory failure, basically, you can have um on the right side, um a effusion on the middle side, you have pneumonia on the sorry, on the on the on your left is the effusion right side of pleural effusion. Uh in the middle, there is some local pneumonia on the right side, they can develop with patients stay for a long time in the hospital. And in more and more important on the right side, there is ads acute respiratory distress syndrome, which is one of the severe complications of systematic complications of acute pancreatitis. Um Next, please. So how would we intervene? Um As in do we operate, do we cut down, do we take the pancreas out? Um It's considered most of the angriest structures in the, in your body. We try to avoid even touching it, but there are some other things that we can do. Um If you go next slide, please. So if a patient has got a gallstone causing pancreatitis, what you can do is um drain the biliary system by a condition called ERCP. So it's basically indicated in acute gallstone pancreatitis with common bile duct obstruction or cholangitis. Um It's normally done under G A most of the cases, but sometimes on the local. Um So you can just spray on the back of your throat and give you some sedation and you can have this ERCP, the endoscope is basically, um, goes down to the esophagus, down to the stomach and the second part of the den, down to the bula of vata. They make a small cut in the bula of vata, uh, by a specialized, um, knife or a dither or cautery, um, which we call the, um, sphincterotome, um, that dilates the sphincter and then they go fishing for the stone. So they insert the basket in the biel tree and they just open the basket and retract, they just fish the stones out and this was the cause for pancreatitis. Next, please. There's um also other things that we can do is we can drain the collections. Um So, indications for pe percutaneous or endoscopic drainage of pancreatic collections in the acute setting is when you have a clinical deterioration or cases with signs or strong suspicion for infected or necrotizing pancreatitis. Um After four weeks, um, drainage is indicated if ongoing gastric outlet obstruction or anin obstruction, um due to a large um necrotic collection, then you can do a percutaneous dr next. So this is what we call a cystic gastrostomy. Um So basically, you go with an endoscope inside the stomach. Um There's a needle knife in uh sphincter tome. Um You make a small incision in the gastric or the Aden wall depends on where it is through the and that uh drains basically the, the, the, the collection of the cyst to the stomach. Um, because normally this is the cyst is develops on top of the pancreas and the pancreas is behind the stomach in the lesser sac. So you can just make the incisions through the stomach wall, going back to the cyst and then drain the cyst into the stomach and you make sure that the area is opened by putting a small stent. If you go back to slide, 33 slide, 33 I'll just, yeah, go back to it. This one. Yeah. So on the scan, on the right hand side, so the left hand side, we said this is a cyst. On the right side, the cyst was drained and you can see that small coiled structure, white structure. This is how they drain it. So they, they put a stent there just to make sure the area is open. OK? You can go back to like 40. So in cases where um if you go next, please, in cases where an infected pancreatic necrosis arise. Open necrosectomy is used to be a traditional treatment method if, if someone can remember in the old days um or in textbooks that we say, ok, necrosectomy is a surgical surgical option here. So it consisted of a laparotomy basically through a bilateral subcostal incisions. After um blunt removal of all necrotic tissue, two large bo drains are um left behind to make some sort of a lavage um of the necrotic tissue. Um The the method contributed to a lot of tissue damage, bleeding. Um a very high mortality like nearly 50% died after this procedure um on high complication rates. So you have like 95% of complication rates. So we need to have a minimum invasive treatment for this. Um So which is basically the percutaneous big tail tube drainage. So we do the drainage as percutaneous, guided by imaging. It's now the first line treatment for infected pancreatic necrosis. If someone's got infected pancreatic necrosis, it is not resolving. Um it's given patients symptoms, the patient is septic, you need to drain it. So you drain it with um the percutaneous um lavage. Ok. Next. So, indications of surgery basically is you have AAA like is it if it's part of the step of approach after percutaneous endoscopic procedure, that's an indication if someone developed acute compartment syndrome, this is an indication um an acute ongoing bleeding where endovascular approach is not successful. This is an indication if someone developed bowel ischemia or bowel fistula, that's an indication as well. Um Next, I think we talked about this. So how we drain a zoo? The cyst is either endoscopically as we've mentioned before. There is a surgical drainage of the cyst as well while you do it laparoscopically, um you basically open the stomach, you go inside and you put some stabs and you connect the back, back of the stomach through to the cyst. Next. So this is another procedure that we can do. Um which is just the last result of anything which is the videos cop assisted um retroperitoneal debridement. So basically debride the area of the necrotic tissue um by um uh a uh endoscope or a videos cope. Next. So this is the, this is basically how the necrotic tissue looks like. Um it doesn't look nice. So after removal of the necrotic tissue, the the videos cop assisted retroperitoneal environment, normally catheters are left behind in place or drains. So just on the right hand side, so you have two drains just on the side just to make some sort of a lavage. Next, please. Abdominal compartment syndrome is a quite important um topic that you need to, you need to be familiar with because um it's basically an increase of pressure inside the abdomen. Um and that and that makes it is similar to the compartment syndrome of the leg, the concept. So you have increased intraabdominal pressure and the patient goes into renal failure and the multi organ failure. And if, if you, if he left behind and not diagnosed, well, not treated, it can develop um multiorgan failure and the patient can die basically. So you need to decrease the pressure by um decompressing the stomach, decompressing um the bowels. Um and sometimes they might need a surgical intervention by opening the abdomen and leaving the open. Next, please. Cholecystectomy. Obviously, if you have gallstones, it's called a pancreatitis um, after it resolves, then you do a cholecystectomy. When is the question? So you can do it on admission. So, if the patient has got pancreatitis, it's settled. You can do remove the gallbladder on the same admission or if they haven't settled, then, um, then you wait for, for the collections to resolve. Um, and then you do your planned cholecystectomy afterwards. Um, ideally it should happen within a few weeks. Promo. Um, Next, please. Uh prognosis depends on the uh if the patient has got what severity of pancreatitis, if they have systematic inflammatory response syndrome or they have organ failure. But as we said, it can reach up to 35% if the patient has got necrotic um pancreas. Um I think we are. Mhm We're nearly there. We're gonna to just be uh do a little bit of talk about chronic panis. Um If you just next, please. Next. So it's, it's a progressive inflammatory disorder. I think most of the things I've already mentioned in my, in, in my presentation, but it's mainly a progressive inflammation um that result in destruction of the pancreas and it does destruct its function both in the groin and, and exo crying functions. Um It's a consequence of severe um it's a function of consequences including severe abdominal pain, diabetes and uh malabsorption. Next place, the um causes are quite similar, but normally sometimes people do do have genetic causes, people who are on chemotherapy and, and with alcohol abuse is the main cause here, uh, of Panis. Next. So they do present in a chronic condition. So they have prolonged abdominal pain. Um, and they do have bowel malabsorption as we said. So they have weight loss. Um, they have chronic diarrhea, nausea and vomiting. Um, in some cases, they can be asymptomatic. So it could be the first presentation of someone with diabetes is chronic panis. Um, they don't, they have a specific form of diarrhea, which is, it's called a uria, which is basically a greasy false, smelling difficult to flush stools because it's, it's all containing fat because you don't have any um any lipase basically. Next. So, lipase and amylase, they're not very helpful here because they can be normal secondary to scarring and destruction of the pancreatic tissue, but is normally, is normally diagnosed with the symptoms, clinical findings and imaging, which is CT and MRI scan. What you see is the Hallmark sign, which is basically calcification, um calcifications uh on top of the pancreas. So that means it's chronic pancreatitis. This is the Hallmark sign in imaging. Uh Next managing it. Um you need to treat the pain and you need to improve the malabsorption. So, um eating small, frequent low fat meals generally helps um and you need to replace the enzymes and exocrine uh functions and endocrine functions by giving them the enzymes in forms of tablets. It's called Creon. Um And if you're diabetic, you're normally just give them, you give them insulin. Obviously, there haven't been any uh mo of surgical intervention for chronic pancre. But um we'll just go next and next again. So I think what we, what we should take home today is that acute pancreatitis can be severe. It does, it can have a very high mortality. Um Treatment is supportive mainly. So you always start with your AC D, you treat the pain accordingly. Um according to your local guidelines or to the um to the global um acute pain management guidelines. Um And it's always multimodal. Um it's not only one medication you give them um food resuscitation is crucial. As we said, it prevents um complications, it prevents um organ failure. Um Surgery is not the main same modality here, but it can be considered as in some cases as we said. Um And it's always MDT Approach. Um And that's basically, I think concludes our presentation today. I'll just have a look on the um notes. Uh We said this necrosis, I think I answer this name, an analgesic drug. It can be, it can be used in patients with um acute pancreatitis. So as we said, it's not only one pain relief you give, you need to have a multimodal effect. Um So you can give um obviously, you start with your bladder. It depends on you going paracetamol opioids and it can reach to PCA epidurals. I think we've answered this on our presentation. Um how do we manage infected acute pancreatitis without giving antibiotics? Um, well, giving antibiotics is, is, is normally uh you need to be a bit protective with the antibiotics. So, um if someone's got acute um infected necrosis and that's proven, then yes, you give antibiotics. Um And we've mentioned what kind of antibiotics will be more efficient. Um But how to prove this is an infected necrosis is depending on many things. So it depends on the imaging findings. So, if you got someone with collections on the CT scan, the collections including gas, this is an indication that this is infected. If you've done your blood test and the patient has got a rising white cell count, rising inflammatory markers. You've done your blood cultures and that grew some um some bacteria, then you should have evidence of, of infected necrotic uh necrosis. Some people do um take samples. So you can do aspiration of um if it's a wall of necrotic collection, you can do aspiration and then that could grow um could grow some bacteria and now you have an evidence and you need to start your antibiotics now. So I think it depends on many things. Um Thank you. Can we use Ryles tube or is it only NJ tube? Um That's a good question. So what are the differences for other people? So, tubes basically are they are nasogastric like Ryles? Um uh They could you be used for feeding like um like NG tubes or they could be for drainage like Ryle tube. Um and the other sort of tubes are naso digital tubes. NASO dial, um, or NJ tubes. So if the patient is consistently vomiting, they are at risk of aspiration in the acute phase in the first two days you need and you've inserted Aryal, so that's fine. Um But if you're, if you're aiming for enteral feeding and the patient is not um able or capable of um having oral fluids, like if they're sedated, they're intubated. So you need to think about enteral feeding but other modalities which are basically feeding and NJ feeding. Normally NJ feeding are, are, are quite depending on your resources. So they're quite more difficult to insert. It is preferable because you're bypassing the pancreas by inserting the tube into the jejunum. But we, we can use as well. Um So if you can have fe and it's only a small amount of trophic feeds on the first few days that you need to know because you need to, you need to give it because you need to um maintain the health of the bowel mucosa. I hope this answer your questions. Um ERCP is a diagnostic uh and theoretic at the same time. Yes. So, but in er RCP, you insert a um a scope into the um through the mouth down to your esophagus, down to your stomach and your first part and second part of the geum in the second part of the geum, you will find a small sphincter and a small bula bula vata, which is if you remember from your um, anatomy that, that, that's a side. And now what after this, you inject a dye and then you do an x-ray, um, the endoscopist will, will know if the bile tree is blocked or not. If it's blocked, then you open the vatter and you put a basket in and then you fish the stone out. Um, so it's diagnostic as it, it shows you there is a blockage of the bowel system with a, with a stone and it's therapeutic because you basically relieve the obstruction. Um, thank you. Thank you. What is the most common cause of acute pancreatitis? Is it gallstone alcohol? Um, I think I've asked the question before to one of my senior and the answer was depends on where you are. So if, if you're, if you're in a country that you can have alcohol, I think your alcohol can be quite similar to gallstones. But that's why I've said both of them can be up to 80%. And when you perform a cystectomy, I think we've answered this in the presentation and there's indication for surgery and when to do a neomy. And what more of a cystectomy should we do? How long should we wait for? Um, when patients develop scopy panis? I, um, I'm not quite sure I understood your question. Ce ok. I think, um, we've gone through most of the questions and this should conclude our presentation today. Thanks everyone for listening and I hope you all well. Um This is a great opportunity given to me by me all. Um And I think it's a really good initiative that you're doing to help doctors and medical students um in the conflict area zones, especially in Sudan, to all my colleagues and to all medical students. And I hope we're all safe and I hope this was very helpful and let me know what other things that I can present and help you in your career. Thank you so much for that talk. It was really, really useful for me. Um I myself, I'm a 50 year medical student, so it was really good revision. Um And thank you, everyone for attending. Don't forget to fill in the feedback form. It's been emailed to you as well and that will help give our lovely speakers some feedback and also for you to collect your certificate. So thank you very much. Um That is the end of this talk. Thank you. Have a good day.