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Hello, everyone. Uh It's great to have you here with us today. Uh Today we have ba back again. Um I think he already has a couple of courses and what I'm gonna do is actually pop his um profile in the chat. So if you want to catch up on his previous events, you can, uh you can get them er, on his profile as always, pop your questions in the chat and we will get round to them at the end of the event. So in an hour's time, you will get a feedback form in your inbox. Please complete it. Um Please give us some indication of what further teaching you would like in this area and, and areas and all the feedback will go back to basil and um your er, attendance certificate will be on your med account once you've filled out your feedback form. So without any further ado cos I know this is gonna be quite intense. I'm gonna pass you over. Thank you. All right, thanks, sir. All right. Hello everyone. Um, welcome to the second episode of uh my Surgical Teaching uh series. And today we're gonna talk about uh pancreatitis which is a, a common thing. Um uh especially when you're on call. My name is Besam and I'm a consultant uh bariatrics and uh benign upper dry surgeon in County Durham and Darlington NHS Foundation Trust in the UK. So we'll start with the um based on the feedbacks that I had last time. So I'm gonna start with uh some objective for this uh session. So the things that we're gonna talk about today is um severity prediction, fluids, how much fluids that you should give, how fast you should be giving them. Do we need to give antibiotics for pancreatitis? Gonna talk also about nutrition, gonna talk about rule of CP and we're gonna talk about cholecystectomies. Um So to start the um the event, we're gonna start with this scenario that a common presentation of patient with this problem. So you are on call and to get asked to see a 40 years old female that presented to the emergency department. She has got a history of 24 hour severe epigastric pain radiating through into her back. The pain is associated with nausea and vomiting. Um She has a background of similar attacks but wasn't that serious requiring hospital admission? Usually that type of pain is related to heavy meals, fatty foods, but usually it resolves within few hours when you asked her about alcohol intake, she denies any alcohol intake and her last menstrual period was about two weeks ago. You noted that on examination, her BP was 100 and 30 systolic. She's a bit tachycardia. 100 and 20 no temperature recorded her respiratory rate um was 18 when examined her abdomen, abdomen is severely tender and the pedestrian. So what's your thoughts at the moment? So, when you get and see this, well, you, we know that today we're talking about pancreatitis, but you have to make your differential diagnosis quite wide varieties of reasons that can present as a big gastric pain. Here's the list of other potentials that you need to consider. When you're seeing a patient with a seminar presentation could be gastritis, gastroenteritis, cholecystitis, peptic ulcer disease, or perforated ulcer, uh appendicitis, bowel obstruction, cystic ischemia. And if you uh listen to the previous um, lecture, not every abdominal pain is a surgical abdomen. So you need to consider some non-surgical causes if you remember that we talked about um, l uh lower lobe pneumonia and inferior MRI. And I can see that some of you already responded with gallstone pancreatitis and II agree the history of presentation of pancreatitis and a previous episode that might be pointing towards B colic type of pain. Yes, I agree. Good. So, here is the blood test that you've seen increased white cell count and crp amylas is 1500 and the wrist as you can see. So we use the blood test to narrow the diagnosis. We need, we use the, the, the, the, uh, the imaging um uh investigations also to narrow down the, the, the differential diagnosis. So based on these numbers, um, what do you think is going on? Yeah, that's true. So, yeah, some of you has replied already. That's good. So it's uh probably pancreatitis based on the um story and based on the high uh amylase level. Good. I agree. So, how do they diagnose pancreatitis in the past? We used to say? Ok, well, pancreatitis is abdominal pain and amylase should be up. And when you say high amylase um times three, the normal limit. Um and I remember that when we were medical students talk about this, but that has changed recently and I would say recently over the probably last uh 1015 years when the Atlantic um uh um criteria came. So with the modified Atlanta criteria for diagnosis of pancreat arthritis that based on two criteria out of three. So the pain should be characteristic pain for acute pancreatitis. So it should be of a sudden onset, severe and radiating to the back serum lipase or amylase should be at least three times the normal and the radiological characteristics of acute pancreatitis commonly on a CT scan, less commonly on an MRI or ultrasound. So if you have two out of the three criteria, you can make the diagnosis comfortably. Uh just to remember, it's uh the diagnosis is mainly clinical diagnosis, not radiological and not laboratory. So if you got a normal MLS, but the pain is consistent with pancreatitis or that you've got the CT finding that confirm pancreatitis. So not necessarily that you're looking at the MLA levels. Ok. So, and that take us back to the basics. So not every high M is, is diagnostic for uh pancreatitis. So for those that are setting their exams like finals or setting their MRC S, you might be asked about these questions o other causes that are responsible for high emys, uh what we call it hyperamylasemia. We know that different parts of the body secrete the amylase enzymes including the pancreas. So, any pancreatic disease like pancreatitis. Ok. Um Pancreatic cyst trauma, E RCP can result in high amylase levels. Again, it amylase gets secreted by salivary glands. So, diseases affecting salivary glands like radiation or parotitis. Um all ductal obstruction again can result in high amylase levels. Gi t disorders like peptic ulcer, perforated bowel mesenteric ischemia, even appendicitis and cholecystitis can result in high amylase levels. Excessive alcohol abuse can result on high amylase levels. And remember with a renal failure, you might get a high amylase level because amylase gets um um renal clearance. So not every high MS is um diagnostic for pancreatitis. Typical um question that you get asked in your uh final exam if you are a medical student. Uh less likely if you're sitting postgraduate exam, but it's still a common questions. What are the causes of pancreatitis? Um And here are the causes and I know that we get, you know, when we start teaching, we talked about get smashed. I'm gonna disappoint you because the s that stands for scorpions, things that, that type of scorpions doesn't exist anymore, but it's still there and people are still talking about it, but the list is there and it's not. Yeah. Um That doesn't include all the causes because even quite recently we start seeing it causes that we never thought about it before, especially during the COVID when we get patients with a COVID uh infection and they, they don't have um uh pancreatitis. Even we saw a few patients coming after the COVID vaccine and they have pancreatitis. So I didn't know whether you have the same experience where you are in the world, but we definitely, I have seen few of these patients myself. Good. So also there are some medications. So if you can't find a cause, remember to review the patient medications because they might be the triggering factor for pancreatitis. Here's a list of few medications out there on the market and they have strong association with pancreatitis. Ok. So people get a bit confused when they need to dig down into the pathophysiology of pancreatitis. But let's make it really simple and easy, straightforward one. OK. So for pancreatitis to happen, need inappropriate activation of the pancreatic enzymes. So when the active pancreatic enzymes get activated in appropriate way, they result in autodigestion process of the pan pancreatic parenchyma that will really re results in vaso dilatation, uh affecting the vascular circ um circulation results in sequestration of fluids, uh degree of vasculitis with severity that can result in necrosis and hemorrhage. So, the possibility you can summarize that in two words, activation of pancreatic enzymes and autodigestion theory. But how gallstones, for example, can cause pancreatitis. That will take us to the theory that is known as transient infection theory. So the gallstones will come from the gallbladder will fall down into the common bile duct. Usually the stones are quite small. So they rarely, they can cause obstruction, but subsequently, with the injury of the endothelium inside the common bile duct that results in edema. And here comes the obstruction. So the edema that on the top of the stone that in the common bile duct that results in a complete transient obstruction of the common bile duct, that obstruction results in increased pressure inside the pancreatic duct. And that activate the pancreatitis cascade, activation of the enzymes and then the autodigestion process. And that's different from the stones that cause cholangitis that again falls down from the gallbladder into the common bile duct and triggers the cholangitis if that stone itself is quite large in size and that can result in a direct obstruction of the common bile duct. And these are stones that need to come out using the E RCP. But again, as a transient infection theory. Ok. So some questions for those who are sitting their exams, bruises and the relation between the bruises and pancreatitis. So, patient with pancreatitis, they might find on a clinical examination, you might find bruises around the um in the flanks in the inguinal ligament. What that mean and what the name of these signs if you found the bruises into these areas. That's probably because that's retroperitoneal bleeding and the pathophysiology of that is called the bleeding. So there is hemoglobin that breaks down into him that gets tagged to the Albumin forming something called Met Him albumin. And that results in a deposition into the tissues into the retroperitoneal space. You can see that as a gray turner sign, which is the black discoloration around the flanks or you can see it as a coolant sign around the umbilicus or a fox sign around the inguinal ligament. Here is the grade turn of sign. You can see the discoloration around the flank and you can see that on the, on the, on the CT scan and you can see the retroperitoneal hematoma, all the bleeding there, call and sign, ok. And for those who try to find links to remember stuff for the exams, cool them with a big C cool and sign with a big C there that comes with the um like that has got big C and um like so for you to remember in the future and again, Fox sign, you can see the discoloration around the groin area there and it all because of the same part of physiology, it's the same mechanism, retroperitoneal bleeding c talking about the severity of pancreatitis. Now, the pancreatitis when it comes to the severity, get classified into three categories, we have got the mild acute pancreatitis, which is the commonest presentation. Then you've got the moderate severe and you've got the severe pancreatitis. So when it comes to severity, three levels of severity, so the mild acute pancreatitis, that's the commonest, that's about 80 to 90% of presentation. And that's uh identified by no organ failure, no local complication. No systematic complication usually resolves within the 2 to 5 days and rarely associated with any mortality. And you can compare that with moderate severe pancreatitis, which is has by definition, transient organ failure. So, the organ failure, mainly the renal that lasts than two days, 48 hours plus or minus all local or systematic um complications. So, it could be uh just the transient organ failure. So it's pancreatitis plus organ failure, which should be transient or pancreatitis plus or minus the local systematic complication in absence of of persistent organ failure. Severe pancreatitis is the pancreatitis plus persistent organ failure, which is more than 48 hours and this is associated with higher mortality rate over than 50%. So, when it comes to the histopathological types of pancreatitis, you've got two types of pancreatitis, the interstitial pancreatitis. Again, that's the commonest presentation. And you've got the necrotizing pancreatitis which thankfully is less common. So the interstitial pancreatitis is just edematous inflammatory tissues and results in the pancreatic enlargement. Ok. With the necrotizing, that means there is part of the gland that lost its vascular supply and it's dent. Ok. And in severe cases that can result in the hemorrhagic pancreatitis. So, patient with pancreatitis, how they behave, what's the na uh what's the natural cause? Uh course of that disease of the pancreatitis. We know that the majority of the patients with more than 80% will be in that category of mild acute pancreatitis. So they normally will resolve uh within five days. These are the majority of the patients. However, there is 20% of these patients will develop local or systemic complications, including organ failure, like renal failure or respiratory failure or even go failure. So, what are these complications that we're talking about? Especially the local complications? So this is the new classification of the complication that definitely didn't exist when I was a medical student. And that could be categorized into less than four weeks complications or complications after four weeks. So the four weeks is the cutoff. So when it's come, uh if it's of interstitial type, you can have acute peripancreatic collection. So it's an area of homogenous density around the pancreas that complication. If it progresses more than four weeks can develop into a pancreatic pseudocyst. So that will develop a um uh a well defined demarcation of the wall will be adjacent to the pancreas and will be homogenous. Uh in, in, in appearance, that's versus the necrotizing picture. We can be having acute necrotic collection. Again, that's in the less if less than four weeks category that can develop further into a world of necrosis. So, when you talk about the complication, because that in the later stage can d um can determine what intervention you're gonna offer to these patients. You need to know are they the less than four weeks or more than four weeks? Are they less mature or uh mature complications? So, you might hear that term mature pseudocyst or mature world of necrosis. And here's some photos for those that are interested to see that. So you can see here the acute uh fluid collection, as we said, that's less than four weeks of the presentation and that can develop into a well defined pancreatic cyst after 4 to 6 weeks. Similarly, is the acute necrotic collection and that can develop into world of necrosis there. So how do we measure this uh severity? Well, there is a scoring system that can determine how severe is the pancreatitis. The commonest uh um scoring systems that we use at least in the UK is the modified Glasgow score. To remember the um items that is called a patient is the word pancreas. You've got also the ransoms, which is common in other parts like North America and Canada. And they use five criteria for admissions and six criteria after 48 hours Apache score, which is the acute physiology and chronic health evaluation scoring system. It's more commonly used in intensive care units. But again, these are different scoring system that can determine the severity of pancreatitis. But generally speaking and away from the um severity scoring systems, um practically is severity is determined if it's within the 1st 24 hours. If the patient is obese or the patches score more than eight, that's a kind of good predictor of severity. After 48 hours, you're relying on something like the E RCP for ex uh sorry, the C RP, for example, if it's higher than 100 and 50 that's again, that's uh a marker for um severe uh severity if the Glasgow scoring system more than three. And if you got persistent organ failure, as we talked about that again, that's a marker of severe pancreatitis causes of mortality. As we said, the majority of patients would survive an attack of pancreatitis. And so 80% will survive will uh recover with no uh complications at all. But those who don't wake up about who uh those who dies from pancreatitis, usually they die from multi organ failure if they die within the first week. And that's because of the severity of this serve the systematic inflammatory response. If it's beyond the first week, usually they die from sepsis. And that's because of severity results in the pancreatic necrosis that subsequently get infected results in sepsis and they die from sepsis. So how would you diagnose pancreatitis? Well, as we said, it's a clinical diagnosis. So it's a two out of the three criteria. So what image do we need to diagnose pancreatitis or probably don't need image because it's a clinical diagnosis. So why people go and chase imaging for patient that presented with clinic with pancreatitis, not to diagnose pancreatitis but to diagnose a cause of pancreatitis. So you might ask, ok, do we need to get an ultrasound? For example, you might want to get an ultrasound to rule out stones or to confirm got stones as you can see on this photo, for example, by why would you go for something like CT scan? Do we need a CT scan to diagnose pancreatitis? The answer is no, if you get a good story of pain, that's characteristic. Plus there is a unlike or like pas that's mo that's enough according to the modified Atlantic criteria. So when do we need Act scan? So you need a CT scan in two situations if you're doubting the diagnosis or you've got a patient who failed to improve or deteriorated after the initial phase, which is the 5 to 7 day winter. So this is when the indication of Act comes in. But before that probably we scan a lot of patients without any reason. Ok. So getting a a scan early, it it doesn't mean anything and it shouldn't be routine. So when you suspecting pancreatitis, rely on the clinical examination and the history and the blood test. But when you're doubting your diagnosis, yes, of course, you can get act scan to find the reason or to rule out other causes. But if you got a patient who's got pancreatitis and they failed to respond, so they're not within that category of 80% of the patient, we need to find why they failed to respond. Why they, they failed to improve, why they deteriorated? Have they developed complications? What's going on then? With this is the second indication of getting a CT scan. Ok. You confirmed that you've got gallstone pancreatitis like this scenario. Do we need to get an E RCP to finish that stone out? Probably not. And the only indication here for getting E RCP in this situation if pancreatitis is associated with acute cholangitis, remember the transient impaction theory. So that stone that got into the CBD will be assured with the edema. And that's what causing the increase of pressure inside the common bile duct and subsequently into the pancreatic duct that edema will subside and therefore the pancreatitis will resolve. But the stone is there. Stone is usually small. They might pass spontaneously into the duodenum, they might stuck there but without obstruction, they're not gonna cause pancreatitis that but the bigger size of stones that cause full blockage of the common bile duct. These are results on secondary infection known as acute cholangitis, these vessels that need to come out using the E RCP. Remember that the E RCP itself can cause pancreatitis with the incidence about 3%. So now we have that lady coming into the hospital, we examined her, we made the diagnosis and now on to treatment. How would you treat these patients? As we said, the majority, the 80% into that category, they resolve spontaneously or what we need to do is to support their body is to support the physiology to cope with the inflammation there. So it's a supportive measures. And when we talk about supportive measures, ok, we need to address three major stuff. So first thing nutrition. So they need fluids and the and the fluids. Uh what type of fluids? Hartman, which is known in other countries may be known as ringo lactate. It's more physiological. How fast do you need to give them? Well, as fast as you maintain the fluid, uh the urine output more than not 0.5 milli uh per kilogram per hour. So you'll be guided by the urine output, whether the patient is catheterized or not catheterized, we need to address the pain. So we need to get on the top of pain and that you can go with the uh painkillers ladder. So you start with paracetamol, then you escalate that keep very close eye on these patients. Look at the observations, monitor for early signs of organ failure, mainly the kidney ok. If they're vomiting, they can put a nasogastric tube, they compress the stomach and as we said, the majority will resolve within 3 to 5 days subsequent management. So once they resolve, ok, what are we gonna do now? Well, we need to address the cause. So commonly it's called stone pancreatitis. So when do we need to take the gallbladder out? So all the current guidelines, talking about taking the gallbladder out performing a cholecystectomy during the index admission, having failed that you've got a two week window to perform an index. Um, cholecystectomy recommended either during the same admission or within two weeks from the admission. Ok. But again, not all the patients will fit into that category. So, patient with severe pancreatitis, for example, ok, you can't say, ok, well, all the guidelines saying I need to take the gallbladder out. No. So taking the gallbladder out within the same admission would be only for the mild pancreatitis. Patient with a severe pancreatitis surgery will add extra burden on the physiology and therefore, the surgery should be postponed again, having a high amylase, for example, or high like pace, that shouldn't interfere with the surgery decision because that's not a marker of severity. If you've got a patient that's has pancreatitis, it's caused by alcohol, for example, then you need to refer them to alcohol liaison team, they need counseling, they need some therapy, other causes will be treated accordingly. If there are a medication that causes pancreatitis. Then you need to look into the alternative to these medications, loading into the next slide. There we go. Right. Antibiotics and pancreatitis. Should we be giving antibiotics as routine? The answer is no. So it's been proven there is no role for antibiotic as a routine for patient pancre for pancreatitis. Remember it's an inflam process, not an infection. So when do we give antibiotics? So the antibiotics would be given only if you got a proven evidence of infection. So if you got infective necrosis on a CT scan, so that would be an area of necrosis with, with, with radiological signs of infection. So that would be air bubbles into the infection area into the necrosis area. That's a sign of infection or you take a sample, you take a biopsy of that could be radiological biopsy or something and you get that, send it to the lab, tested the microscope and proven there was an infection there. Therefore, you need to give antibiotic but not routinely. So the only indication for antibiotics is infected, pancreatic necrosis. Take some time to load anyway. Ok. Here we go. All right. OK. So how do you feed this patient? So remember that part of that supportive uh treatment nutrition and if the patients are able to eat, they should be fed. So the protocol that we used to have in the past have some gut rest to reduce the production of pancreatic enzymes is not viable anymore. It's now proven that feeding this patient support, the God, support the immune system, support the physiology is far better. You've got two ways of feeding these patients either intra so they can eat themselves or that's through, um, tube feeding or could be current on nutrition. The TPN, which one is better in terms of evidence, it's very dependable. But we know that it's the enteral feeding that protects against the bacterial translocation and secondary infection, that's been proven. So whether they can have the food themselves or you put the tube down. So whether it's a NG nasogastric tube or N GJ naso gastroin tube, um that would be far better and you can have the double lumen tube. So one lumen would be used to aspirate the stomach and the other tube will be used for feeding, which is going further down into the Jegen. And that's far better. And that's what I use on my practice. If they're able to eat, that's great. If not, then they can support it by internal feeding. And we rarely go for parenteral feeding if they've got uh gut failure and that's only happens in really severe cases. So, in a summary, how would you diagnose pancreatitis? Two criteria out of the three modified Atlanta criteria, abdominal pain, plus the serum amylase or lipase. That's times three, the normal plus, you've got the radiological evidence of pancreatitis causes of pancreatitis. We talked about it. Treatment is mainly supportive treatment. Don't forget the nutrition. Don't forget the fluids. Don't forget the analgesia E RP only when the visits to an impacted in the common bile ducts. And as she with associated cholangitis, remember, timing of cholecystectomy is crucial in mild acute pancreatitis. Cholecystitis will be within the same admission or within the two week window from the admission in s in severe cases. That should be delayed intervention again for complications, try not to have any intervention within the first four weeks, wait for this complication to mature what I mean by mature, having a mature pseudocyst or mature uh pancreatic uh necrosis. And I'm gonna leave this here just for you to remember the things that we talked about, which is the two phases, the early, the late phase. That's where the pathophysiology changed the severity and the interstitial and the necrotizing types and the complications at the bottom. And we can have time for some questions, please. Perfect. Uh So yes, if anyone has any questions, please pop them in the chat. Now, obviously, your talk went above my head. So I'm gonna go back through the chat and see if there's any questions that have been put in here that I'm unsure of or maybe they might be a question for you. Um I think it was a couple of last ones. Um Far ahead. Put, how long should one wait before intervening in symptomatic Pseudocyst? So when you have a pseudocyst, um as we said, the Pseudocyst will form after the four weeks window. So this won't become mature most probably, um, in, in, in, in lots of cases, these pseudocysts um, will be asymptomatic or they might initially cause symptoms and gradually the symptom will disappear and the cyst will get smaller and smaller. But if the cyst is persistent and you've got, um, uh, symptoms caused by the pressure effect of the pseudocyst and it, it got it, it, the cyst has got a very well matured wall. Then this is the time where you can intervene. So, generally speaking after the four, definitely after the four week, winter and usually six week plus, this is the time for intervention that could be a radiological drainage or it could be endoscopic or laparoscopic cyst to gastrostomy. So you drain the cyst into the stomach. Hopefully, that answer the question. Uh, far it's got quite a few questions on here. What is the best timing for an elective? Oh, cholecystic cholecystectomy. That's the one. All right. Good. Ok. So again, we, we talked about that. Um, so, um, cholecystectomy when it comes to pancreatitis, if it's mild pancreatitis and the patient is fit for surgery, ideally speaking, within the same hospital admission, and that's what they call it the index admission. So, if you got a slot on your co that your emergency list and the patient is fit to have an operation, this is the right time to do this operation in patient with mild pancreatitis. If you can't fit them due to a reason or another, then you've got a two week window where you can fit them, get them back, put them on the list, take the gallbladder out. If you can't do this or the two week window, then will be delayed six weeks after the attack. That allows the, um, things to settle and then you can do it in an elective setting. When it comes to the severe pancreatitis or moderately severe, you will be guided by the clinical improvement of the patient. Ok? Because the last thing you wanna do is to increase that insult on the patient physiology by giving them a surgery on the top of the severe pancreatitis. They've got, ok, perfect. We've got more in the case based discussion provided at the beginning, she presented with bile stained vomiting. What could be the cause of this presentation? I'm thinking of either a paralytic ileus secondary to the inflammatory changes brought on by the acute episode or G gallstone is oh, is an erect abdominal x ray wa x-ray warranted. Um Not really. So if you do look at the examples um that you put as paralytic ears or the uh go to Ili. Um, so that's forms of uh bowel obstruction. And with the paralytic ileus, these patients, if they vomit, they're gonna vomit intestinal contents and sometimes they vomit frequent material, similar thing with a gallstone ileus. So that's doing that sitting somewhere in the small ba bowel most probably towards the terminal area and then they vomit small bowel contents. Uh Yes, it could be green bile sometimes but sometimes it could be frequent material due to the fermentation of the food in the gut. Do we need to do an abdominal X ray? Uh not for the diagnosis of acute pancreatitis, definitely, but there are some signs if you're interested, there are some signs that you can look for. If you do an abdominal X ray, something like the colon cut off sign, for example, or the sentinel loop sign. These are the signs that can be sometimes if you got a good abdominal X ray, you can look for with the cases of pancreatitis but not as routine. Ok, perfect. Next question from far. Uh how important is the ct severity index in unresolving episodes? Does it influence management? Uh Yes, it does. And I think that's a really good question. So if you work in a Hepatobiliary unit, you will find that they do CT scan on a regular interval in patient with severe pancreatitis or those who are unresolved and those who are unresolved, they unresolved because they have developed complications that we talked about. So they monitor these complications by getting regular um CT scan at regular interval. So every week, for example, or every other week, for example, to ascertain what's going on and then decide when they need to intervene. So they can monitor the progress or the deterioration of the patient, but then also can determine when they need to intervene and usually that's beyond the four weeks window. Uh Next question, how to differentiate clinically acute pancreatis from acute or chronic pancreatitis without radiological evidence or of calcifications? Well, that's mainly by the history. So the acute on top of chronic, that means that patient will have definite history, previous investigation on your um local hospital system that proven um that he had previous pancreatitis. Ok. And in these cases, what you might find a bit challenging that the MS is not um II is not rising because of the damage to the pancreatic levels. Uh So you rely on the clinical examination on the CT scan, not necessarily that you look for calcification, but you look at sometimes at pancreatic atrophy which could be a sign of chronic pancreatitis as well. Ok. Next question. Uh I was told to wait at least 7 to 14 days before the CT exam of the abdomen because that's when we are likely to pick the pseudocyst and other complications of the pancreat test. Yes, and efficient cost utilization. How does that stand with early CT for diagnosis? Yeah, I completely agree. That's what we talked about. We said there was no early ct for diagnosis because the diagnosis is mainly clinical. The only indication for CT early in the course uh in the course of the illness. If the diagnosis is not clear, if you are in doubt if you haven't got a definitive diagnosis and you want to find out this is when you want to get act. But if you got a clinical evidence sufficient to make the diagnosis of pancreatitis, definitely you don't need CT and I completely agree with you. You need to wait at least seven days before you get the scan. This is when you start picking up the complications. That's great. And I think our last question uh in necrotizing pancreatitis, do we give antibiotics as part of the conservative management? Uh No, unless there is evidence of infection. Um And that needs to be proven either radiologically by finding a cules within the necro nec uh necrotic tissue. So that could be a sign of infection or by obtaining a biopsy and get that tested and proven there is an infection. And this is the only indication to give antibiotics unless definitely, unless, yeah, I mean, obviously, if the patient has got other reasons to give antibiotic that like chest infection or uti or something like that. But when we took purely on pancreatitis, um the only indication is infective pancreatic necrosis. Ok. I've got one more question. That's all right. That's right. What is the management of recurrent pancreatitis due to congenital pancreatic duct anomalies, surgery versus E RCP? Right. This is where it gets really complicated and usually this decision, it's a joint decision within the HPP MDT S. But again, stenting is an option, surgery is an option. There is pros and cons for each of these options but nothing definite. And the, the you there is multifactorial that you need to look at when you consider these options, considering your patient functional status, uh fitness for surgery, if they're gonna go down the route of surgery and the facilities, if, if that you might have in your unit or you might want to refer to a unit which they offer this kind of treatment. But the decision in this is beyond the general surgeons and kind of D GH hospital, that's where you need to refer these patients to the tertiary centers. Uh for specialized um H PP opinion. This could be our last question. It might not be what are the indications of surgical intervention for pancreatic er necrosis? Well, if they are symptomatic, so any of the complications, if they are symptomatic, this is where you need to intervene, whether it's pancreatic necrosis or pancreatic pseudocyst. So if they are symptomatic, if they cause troubles to the patient, then you need to intervene and the intervention for the necrosis, there will be the video assisted necrosectomy. OK. Compared to the old techniques of open necrosectomy, uh or laparoscopic necrosectomy, which probably have got high mortality rate. I think we're done. All right. OK. Do we have any other questions or did I miss any questions in the chat? Anyone if you feel I've missed your question, copy and paste it back in again and we can, we can get around to that one. There's lots of questions. There wasn't there. They really put you to the test, didn't they? Ma II? It's a good, that means that they're listening and they are interacting. Uh Sometimes it's very difficult just talking um to the screen and you can, obviously, you can't see faces um who's watching, but it's really good to see that people are interested, people keen to learn and that what promotes these uh lectures and that what promotes that platform in general because yeah, the more that you get from colleagues and students that more, OK, you won't put effort into it. Yeah. Yeah, absolutely. We love that. We, I love it when the delegates are asking lots of questions because I'm not medical. So I haven't a clue what to ask. So when they ask lots of questions, it's brilliant. So, does anyone else have any other questions? I give you a couple more seconds to type something in or copy and paste something in um like I said on the hour for me. So in 10 minutes time, your feedback form will be in your inbox. Um Please complete that. Um This recording will be up. I'll try and get it done this afternoon. If not, it'll be tomorrow. Um and you will be able to access it. If you want to share it with any of your colleagues, we really recommend that. Please do share um Bassam is actually on Twitter as well. So you can find him on Twitter if you want to and you can tag him um and share the, the, the talk. We really just want to get this education. It's such good education, it's such good learning. We really want to get it out as far as we can. So tell your friends, tell your colleagues, share it with anyone. We'd love to get them on the platform. And like I said, fill out your feedback form. Let us know if there's any other pancreatic issues that you want to learn about that. And what other things do you specialize in, in what other things might they could you teach on? Um Well, um I'm a benign upper gi and bariatrics. Um So we can talk about biliary diseases, cholest stones, um cholecystitis, um hiatus hernias, for example, we can talk about the emergencies when it comes to bariatrics. Um We can talk about bariatric procedures. Uh We can talk about um Yeah, gastro severe reflux uh peptic ulcer disease. I put your eye bleeding. Uh It depends what they want to hear about. I mean, if they, they put these into the comments or to the feedback, then we can plan some sessions around these topics. Yes. And that is perfect t to what they want to hear. Yep. Yep. So you heard it first? Oh, can we have next meeting on gallstones? Peptic holsters? Look, you're getting it, you're getting the feedback. See this is what we want to hear if you could put this also in your feedback form so that we actually have a copy of this. Um As I said, I will be passing on the feedback to bathroom anyway. So then we can start looking to see what everyone else is asking for and we can work through the most popular and then go, go down, down the rest. All right, because we would really love to provide teaching that you want to listen to, right? There's not much point you must provide in teaching that you won't turn up to. So please do let us know. This is for you. This platform is for you. You know, this program is for you. What do you wanna learn? Let's see if we can get you some people on who have incredible knowledge and are incredibly gifted in teaching. Let's see if we can get them on to teach you what it is you want to learn. All right. So please do fill out the feedback form. I will pass it on. Please do share the recording with your colleagues, your friends tell everyone about us so that we can get more and more of you on the platform because that has to be good for our global health care, right? If we're all learning the same stuff and at a high quality that has to be good. So please do share about us and hopefully we will see you at our next middle education event. So beam and I will say goodbye to you for now. Thank you very much for coming and um please fill out your feedback forms. All right, everyone. Take care. Bye. Thank you.