Video Case Based Question & Answer Session on Gastroduodenal and Pancreaticobiliary Play Pause Volume Quality 720P 720P 576P Fullscreen Captions Transcript Chapters Slides Case Based Question & Answer Session on Gastroduodenal and Pancreaticobiliary Overview Case Based Question & Answer Session on GI Tract, Acute Pancreatitis, Chronic Pancreatitis, Gallstones, Pancreatic Neoplasia, Neuroendocrine Tumors Oh, hold on. All right. Great. Thank you for joining us today. My name is to teach Nakoula. Welcome to our second live Q and A session for the eighth annual Mount Sinai Intensive Board Review and Gastroenterology and Hepatology Way have today we're going to be discussing pancreatic A biliary diseases. We have an outstanding panel with us first introduce my CO course directors Ari Greenspan and Pascal White. And then on our panel today is Doctor Michelle Kim, Dr Chris DeMeo, Dr Amy Lucas, Dr Nick Herder, Dr Tina Park and Dr Ed London. Um, we're gonna run this format similar to last week for those of you who are here with us last week but for the new attendees, basically, we have some pre made questions, um, that are sort of in a board review style to sort of spur on some discussion. But really, we're here to answer your questions. And so there is a Q and a box you'll see at the bottom of the top of your screen, depending on what device you're using. So feel free to type in any questions there, and we'll certainly oppose them. Thio speakers on Do you know our goal here is certainly board of you. But if you have other just sort of broad clinical questions that are generally applicable to everyone, they were happy to discuss those as well. So with that, I'm gonna ask Pascal to go ahead and share her screen, and we'll start with our first question. Okay. All right. So you've given away the topic. So our first question here is a 40 year old female who presents with severe right upper quadrant pain fever, new jaundice. Uh, she drinks three alcoholic beverages per week. Never been hospitalized except for the delivery of her three Children. Their serum, Emily's and life paste levels are increasing more than seven times normal. And lt of 3 80 she's been receiving prospect of antibiotics and submission, but she continues to have symptoms including abdominal pain, nausea, vomiting and fever. What's the following is the best course of action. Uh, I'm gonna ask Dr Park to China. And so this patient has, um, pancreatitis, based on her symptoms and like peace elevations. And most likely the ideology is gall stones, given her age, gender and fertility. So a female 40 um, for all the s um And so for gall stone pancreatitis. Um, not only that, she has also fevers and ongoing p despite antibiotic. So she also has symptoms. Suggestive cholangitis. So for this patient, um, she will benefit from urgent ercp. And there's really no need Thio obtain additional imaging to demonstrate that she has dilated bile ducts or biliary stones before proceeding with the RCP. Uh, Pascal, you wanna go on to the answer that great. Um So as Tina mentioned the lack of signal alcohol history increased lt level, um, she had mentioned this is most likely a biliary pancreatitis, given the persistent symptoms, including fever, is indeed an ercp, uh, to treat cholangitis, particularly the ongoing fevers. Um, Chris was gonna ask you to comment Any thoughts about the need for imaging or, you know what? You're sort of clinical practice. Well, I think it's always good to have some type of initial imaging studies. So, uh, you know, typically the easiest and most cost effective, uh, test is abdominal ultrasounds readily available, usually can be done any time in the emergency room. And I think in this situation, if that showed gall stones or a dilated bile duct, Aziz Tina said your since your diagnosis of gallstone pancreatitis and can proceed to Ercp. Um, you know, things always get tricky if the ultrasound doesn't show any duct dilation or gall stones, and then you may be looking at alternative diagnoses. Um, which I think initially hers were all negative initial work of them, right? Absolutely. Um and can you comment a little bit on either in your experience, maybe the role of either endoscopic ultrasound or M R C p Either this patient or in general, we were thinking about patient with cholangitis for me. I missed you know, I was asking it. I'm sorry. So I think for the enroll of cholangitis, you know, it's really a clinical diagnosis and we have to go with the clinical parameters. Um, such as in this patient with fevers and elevated white count. Um, I think if you have a strong enough clinical suspicion, you don't want to delay the clinical care with trying to get an m r I on arm RCP because even if it doesn't show a stone and your clinical suspicion is high, it's probably not going to change the ultimate management, in which case where you're gonna go toe ercp. So I think that it gets again to the point of following the clinical parameters and not delaying the care, especially in the case like this, Absolutely agree here. You know, we're sort of in an area where I feel like everyone reaches for yet another skin. So a lot of times, this patient, if they come in a 10 o'clock at night, they're getting an m r in the middle of the night. Um, but the clinic, our criteria here basically tells you you're gonna have to do New York CP regards for that M r. I shows. It's sort of a great story and a great, um, case here that really is consistent with gallstone pancreatitis with Colin Chinas. Um, Pascal thinking going to the next case 50 year old woman presents to the e d. Her further management right Upper quadrant page. She's normal. Intensive in a federal on exam, she standing up How patient in the right upper quadrant with guarding but no rebound lab to reveal a total bilirubin of 1.6 and outlined fossil taste of 75 N. A S, T F 40 and lt of 35 like pizza 20 and white count of 11.1 earlier. 0.7 right up a quarter. Ultra Silence obtained reveals a five millimeter CBD. They can call butter wall Perry cool assistant, fluid and cold with diocese. The next best step in management is, um, Tina thoughts here on this one. Yeah, sure. So this woman seems tohave on the cute colossus status based on her abdominal team. Um, and ultrasound revealing thickened gall bladder wall and Cherry cola. Cystic fluid. So based on that, I would recommend the surgical referral for cola. Suspect me. Now she does have very mild elevation in her total bilirubin. This question doesn't really specify whether it's indirect versus direct, but her rest of her eloped either. Really, not impressive. Normal Auckland facilities on ultrasound doesn't really reveal a biliary doctor relocation, so she doesn't really have a lot off factors that would be either. A strong indicator are very strong indicator for cola. Vocal advice is so I would go with E, um coal assist ectomy. Now, if you were to kind of observer further in clinical scenario and her lefties are a little bit higher than this with higher Billy ribbon, you could consider image ing first. But with this kind of Billy Rubin and lack of allocations are pancreatitis or any other. Um, sometimes I would go with cola. Suspect me. All right, great. That's certainly the right answer. Um, and then onto the discussion side. So as you mentioned correcting Nicola cystitis any coal assist ectomy on you mentioned these predictors of cola, Jokela, thigh ASUs. Um, you know, the she only doesn't really have any strong predictors of cola Jokela, thigh assis. And so it could go right to calls to step to me. Um, what's been your experience and having surgeons, um, perform IOC s Tina that it's not their favorite procedure. I think with, you know, that against those off imaging, particularly M r c p. I think most surgeons or even gastroenterologists really like obtaining noninvasive waste image. The bile ducts on that tends to be the m r c p, um, or whatever reasons. If you couldn't get that because of ah, peacemaker issues or claustrophobia or body weight issues, and I think you can consider either endoscopic ultrasound or IOC, right? Yeah, it's incredibly institution dependent and physician dependent in a previous institutions. I worked at. No one likes doing IOC at M s h. Fortunately, a lot of the doctor, a lot of the surgeons here will do them, but there are a few who don't. And so it's very institution dependent, probably cause it's kind of clunky to do it. And so it just becomes a cultural thing. Um, Chris, if the patient had a higher billion, is there a believer then? I mean, I know this question, answer. And even the guidelines talk about this 1.824 range. Is there Billy Rubin where you feel like further imaging is necessary Or like, what? Your threshold for recommending an m r or even in the US So I think the SG guidelines that you mentioned here talk about a Billy Rubin above four is a very strong predictor of bile duct stone. Um, you know, I tend to be a little bit more conservative, and I like to have a much evidence is possible before committing a patient to an ercp. Um, you know, as we know, ERCP does carry a risk of pancreatitis and strength around and carries the risk of bleeding so you never want to go into a near CP with weak or moderate level evidence that you have a stone because you may end up doing more damage than you know. It's a It's not a benign intervention, eso you know, And I think we talk about these cases every day. I one of the things I look at it is, yes, the level of Billy Room. And if the total Billy Rubin is very high above four, I think that does play out. That's a very strong predictor. I think the other thing that may be beyond the limits of this question is just sort of the trend of the LFTs. Um, you know, I think that depends on when the patient presents etcetera. But if the trend of the LFTs is going down, I think most of us would would likely say, Okay, this patient probably pass the stone already and may not need the ERCP or need further imaging or anything like that. Uh, yeah. No, that's Zacharek to try and develop teases certainly really useful when I think the Mayo Clinic has some data on this, but kind of makes sense that the LFTs aren't going down very quickly. Then you definitely have to worry that there's something still there. Um, there's a question from the three audience here, and whoever wants to comment would be great. Which is can anybody comment on the newer A SG guidelines, which I think is from last year or the year before? Um, which Narrow went Ercp is indicated? Does anybody wanna comment in particular? You know, I I will kind of threw out that that the guidelines tend to move a little bit away from Ercp Onda certainly a little bit more towards using a US, which is something that a lot of us who do both procedures, um, strongly favor and exactly it's Chris alluded to UM e R. C P is not a benign procedure and all and of all G I procedures like routine G I procedures. It's got the highest complication rate. Eso It kind of supports the practice that I think many of us do, which is any time there's sort of some borderline issue. It's easy enough to do, um, a us if it's available. Otherwise, um, you know, going to m R C P. And I think the old guidelines from about 10 years ago kind of went use a lot of predictors to get the Air Cp. And for us, I think in a lot of patients who are sort of on the borderline, we we tend to go towards a bit more us. It was not to delay their care. Uh, see, next question. Yeah. A 28 year old African American man with the sickle cell trait develop severe right upper quadrant. Pain with vomiting is paying less Approximately four hours and a plane film of the abdomen shows castle identities in the gall bladder. Which of the following statements about these densities the most likely correct? A. They're brown are not gonna read all through all of those. Um, uh, if you want a comment Yeah, sure. Eso He's got a sickle cell trait, which is a hemolytic condition. Eso most likely he's got black pigmented stones rather than brown or cholesterol Stones. Um, cholesterol. Stone tends to be the most common type of stones brown pigmented stones we tend to see in cholangitis or acute infections. Eso just looking through the comments. I mean, the answer choices A will be incorrect. Um, be he would likely not benefit from arse Odile as that's more effective and those with cholesterol stones and our suspicion is that he's got black pigmented stones, which are composed of calcium. Billy Rubin e as the answer Choice City suggest, um, but it does not account for 80% of common bile duct stones. Those air, mostly cholesterol stones will still be incorrect and answer choice T services. That is a respecter for black pigmented stones on that does contain less than 50% of cholesterol. So I think this is the best answer. And, um, answer choice e that you are in all their particular, as far as I know, is not really a risk factor for information of stones within the viaduct. So I'll go with D. Great. Excellent. Um, you know the imagine these castle identities air Certainly gall stones. It's It's interesting You don't see that too often on on playing on a plane. Films Every so often you might see that's kind of fun when you see it on Fluoroscope E. Um, you know, they are black paid bank of stones, which are related analysis and Soros system. They form with the gall bladder. Um, the one of the answer choices. There talks about using er. So denial. All I will say is, please don't use or so denial. They just come back later with the same stone problem. Um, it is amazing how many patients will latch onto it or some practitioners. But those practitioners did not attend this corpse. So you heard it here first. Um, so our hopefully not first. All right, let's go to the next question. Alright? There are under consumer questions. So this is a 60 year old male undergoing a screening colonoscopy, a five millimeter tubular adenomas found in the Sikh, um, and moved in the rectum. Eight millimeter nodule was identified in the U. S. Exam demonstrate the nodule is hip Ochoa confined to the 70 cosa. What is the next best step? Um, shell s a T shirt. Was kind of hoping you would call on somebody else s. Okay, So, knowing too much eso perhaps so. I think the first teaching point and this is perhaps, you know, just to make sure that this is a low grade tumor. So, um, there could be different grades, low intermediate and high grade tumors, and you want to make sure that the pathology identifies not just during a consumer, but also that it's a low grade tumor s o that was, let's say the first step. But in terms of the answers here, um, in terms of you know what would be the next best step? Um, you know, we're going to say that it's it's gonna be performing endoscopic mucosal resection essentially with the US You've ruled out that the tumor goes deeper than set mucosal. You also have presumably ruled out any presence of Perry rectal lymph nodes. And so this appears to be a respectable lesion. And for that reason, M. R is the right answer. Um, we can talk a little bit later, but this is ah, less than one centimeter lesion. And so this is not something that you would typically refer for surgery. Those air usually reserved for patients with, um, larger tumors, often 1 to 2 or two centimeters. Repeat, colonoscopy is not gonna particularly help you in this situation. And I think actually, D is a good question, which is, um, asking about the serum five h i A A. This is generally associated with more mid gut tumors, not with the rectal. None of consumers those. They're not going to give you the carcinoid syndrome. So s. So. That's not the right cancer either. And so be is the right answer. Great, you know, And as you had alluded to, the size is critical here, right? So thes rectal neuroendocrine tours are generally asymptomatic. They do not produce five h I A. But they can be testis size, and it's really that's related to sites. So less than one centimeter endoscopic treatment is the treatment of choice. Andi, When it's over two centimeters that have to go for surgery once you're in the between the one and two centimeter range, there's just a lot of factors that come into play here. I can't imagine that they would ask anything related to that on the board, because it's just a lot of the big gray area, Um, certainly in the area, especially in the era of endoscopic, except because of dissection or folding Mr Section and so on. So but the key here is, um, you know, less than one centimeter. Um, and if you can come into a little bit, you know, the US here talks about a lesion confined to the 70 cosa. Um you know, it's good to you know that whenever you look at these tables that show all the different types of lesions and where they originate from, um, can you sort of tell our attendees maybe, like some of those common things they should think about when looking at sub mucosal lesions on the U. S. Sure eso So basically, when we're examining these under ultrasound, it's sometimes hard to discern the muscle layers and anyone who's doing a lot of endoscopic ultrasound. We're always sort of. We keep chasing our tails and looking at the same image because we want to be really sure, because depending on that wall, it really will dictate how we approach it. Because if there's any invasion or any deeper involvement below the sub mucosa than, obviously, it's not amenable to EMR. Um, in addition, when we're trying to classify these lesions, um, it helps to sort of understand before you have a tissue diagnosis. What later is in because, um, depending on the wall air that is involved will help, um, narrow your differential. So, for instance, if if you actually do in the US and you don't have a biopsy and audit yet and you don't have a tissue diagnosis. If it's 1/4 later, that's a big difference, right? That's you know, then you're thinking more of in terms of, like a G I stromal tumor or perhaps ally Oh my oma. So it can change the differential. But certainly once you have the tissue diagnosis, if it's coming to us on, were asked to do in the US it really helps us decide if we how we should approach this regardless of size. Because if you have a smaller lesion that's going into the appropriate to the fourth layer, then at that point then you're thinking something a little bit more radical rather than just a m r. Uh, that's correct. And I think if we think about boards related stuff in the kind of detail of things they may ask you, um, you know the subject Cosa is a couple of made legions to think about. So certainly in this case, we would think about, uh, like a neuroendocrine tumor. But if it's a different color, brighter color we call hyper Co, you might think about like coma Christie of something you'd like to add on that. That ad real quick, it zits important for the audience to understand. You know why surgery is needed for the two centimeter lesion. It's not that that cannot be removed. Endoscopic Lee. You know now, with newer techniques, large lesions can be removed completely by endoscopic methods. It's that, as you mentioned, the risk of metastases is greater. So if if you have a lesion that's 2.5 centimeters, there may be micro metastases to the localized lymph nodes. And that may not be evident on any kind of image ing, uh, study. And that's that's where surgery comes in. It's not so much surgery to remove the primary lesion. It's to get the localized lymph nodes and prevent recurrence and spread from micro metastases. So I think that's important for people to know, because e think we've all encountered cases where I'm sure Michelle Count encounters this all the time. Where somebody comes in, they have a lesion and it was removed, and it may be above that size threshold. But then they're told, you know, you still need surgery and they're like, Why, you know, it's been nine legion. It was completely removed, so I think it's important for the audience. Understand that? I don't know if Michelle is any other comments to add to that. No, that's exactly right. Actually, the point that I was gonna make also was that because it's much more common to see smaller lesions. Is that you know, if you're if you suspect a rectal carcinoma. And I would really strongly recommend just taking a biopsy, because I can't tell you how many times we're then left with somebody who's done a polytech to me. Where, um of course, you have tumor at the cauterized margin, and now we can't go back and find where the lesion is, and we're sort of left trying to find a needle in a haystack. So if you suspect a rectal carcinoid, please just biopsy it or, um, tattoo it or do something so that we can tell where to go back. If it is a carcinoid, Um, that's cool. If you can show up the next question, uh, real quick. I think that, uh, Ed had a quick question or a comment he wanted to ask about this prior case. It thinks I just wanted to ask, uh, the other folks on the on the call. How would you follow this patient up? How would you survey them? E most certainly call the show. E. Don't call May. There's no right or wrong answer. You know that. It's a really tricky I'm situation. Unfortunately, I've I've been, um uh, because of my specialty in this field, I've actually seen, um, some localized spread from patients with very small tumors, which is sort of a scary thing. So I tend to follow them longer on bmore. Um, conservatively. That I would say most people in the field a za a follow up to that. Sometimes we see these hyper plastic appearing little rectal polyps, and you biopsy it. And you you think you got the whole thing on it comes back as a rectal carcinoid even even think that it was gonna be a rectal carcinoid. Then the pathology says that that's what it waas do. You then bring that patient back for a flexing and make sure that the entire Pollock was gone. Or do you bring them backs and some other, um, interval based on again not knowing that it was a record. Cars to to begin with. What do you usually recommend to patients in that e. I usually try to bring them back to do a flex sick and a rectal us. Andi, again, this is, you know, somewhat overkill. I'm not sure that everyone agrees with this, but, uh, you know, they're definitely been times when we've been able to go back and find the tumor doing EMR and get clear margins. And that's really what you're looking for. Um, And then again, you know, depending on the size of the tumor, depending on the grade of the tumor will also do in the US to make sure that there are no Perry rectal initiatives. Do you want me to read out the second question? E assume that this is acting way? Have a question from the audience. Uh, if these lesions are sub mucosal, if you just biopsy, what is the risk of not getting deep enough for a tissue diagnosis? Yeah, actually, you know, you would think that perhaps you might not get enough tissue, but I would say that almost everyone gets tissue on biopsies and they whether it's a biopsy or a polytech to me that you do because you think it's a polyp. Um, everybody gets tissue on DSO. I wouldn't worry, actually, that you're not gonna get tissue from just a regular mucosal biopsy. Sometimes when you biopsy on top of the biopsy site, especially, it was just jumbo biopsy forceps. You tend to get a little bit off the stuff mucosa. And that might be helpful if you're suspecting something more sub mucosal. And you're worried about that? Yeah, I agree with that. I think the only thing is for some reason I don't know that the Rectal Carson I must have some mucosal involvement as well. And so that again, with just regular mucosal biopsies, we seem to be able to get tissue. It's always an unpleasant surprise because you think it's me causal process. Yeah, okay, we're gonna move on to the next question. Unless there's anything any any other comments or questions from the Panelists or from the audience. Oh, okay, questions. Next question. A 40 year old man with metastatic gastronome, a developed severe dysplasia to solids and liquids while on treatment for his tumor, he is on a tree, a tide and high dose proton pump inhibitor in pill form, E g reveals circumferential distal esophageal ulceration and a severe stricture with loom in less than five millimeters in diameter. What is your recommendation for treatment? Michelle S O E. I think pretty quickly we could narrow down our choices to see which is to change the P p I to the dissolvable form. Um, you know, when you're dilating, you certainly want to be careful about dilating from five millimeters all the way up to 15 millimeters at one stretch on H two. Blocker is not necessarily going to do much more in terms of resolving this ulceration and structure. And its object to me certainly seems a little bit extreme for somebody who has not gone through a medical therapy. So this is ah, peptic stricture that you want to address with the dissolvable form P p I. And if I could just make one comment here about gastronomic, I think just really want to emphasize toe those folks who are thinking about gastronomic. That's such an easy diagnosis to make. You could just check a gastro level on. This is one of those, you know, zebras that that if you catch it, um, that it could really change the outcome of patients. Um, clinical course. Onda again if you have reflex and diarrhea reflects an abdominal pain reflects and ulcers or very complicated reflex. I think it's, um you know, behoove puts us as gas Ramallah just to at least think about the possibility of gastronomic and again just checking a very simple serum gas. Trine? Yeah? How, Michelle, do you have to follow those serially if you check this the gastronomic initially s o I. You know, actually, with my practice, I don't typically follow Gaston is much like once I know it's a gastronome. A That sort of tells me the answer, and I am following their imaging toe Look for tumor progression. Um, but, you know, again and just making the diagnosis a serum gastro is really invaluable. Yeah. Um, Tina, can you comment a little bit about dilating someone like this with active ulceration? Kind of, You know how how far would you go? Or, uh, you know, what guidance would you have? S o. I think generally the way we were taught for most folks during fellowship is, you know, be careful out. Be careful about dilating more than three millimeters at a time because of risk of perforation. But you have to dilate enough to see some sort of a superficial tears or stretched to indicate that you've done effective violations. Um, but you also want to kind of be cautious the same time. Eso What I tend to do is I dilate, um, up to three millimeters and I try to look through the balloon, um, dilator for any signs off mucosal terrorism kind of gauge from there. If I feel comfortable, sometimes I'll push it thio, dilating even four or five millimeters at a time, depending on the ideology of structures. When there's also rations going on, you do have to be careful. I like them to treat them with P p I first and let the inflammation to heal before dilating. Um and s. Oh, this is really for benign strictures, I think malignant strictures. You have to be extra careful, um, their increased risk for perforation and terrors, so it kind of depends on the situation, but I'm generally cautious, so I'll reassess after violating three millimeters. It is a great point. The rule of threes I actually had looked at recently was basically just made up. Like some of staff Ecologist from the seventies was like, let's just try up to three. And that turned out to be I think Joel Richter is mentor who did it. And so Joel Richterova no tutorial where he hunted it down. And, yeah, it's basically, you know, garbage. Um, So what I tell fellow is exactly what you just said, which is dilate. You look like you did something because you don't crack the fibrosis and you just kind of pushing things aside and just it's all kind of came right back in. So theater of ulceration. Is that a huge piece? You know, you want to dilate fibrosis, Andi, that you can crack that, but if you have an alteration, you're just cracking the wall, which is not gonna end well. So, um, question from the audience Um, Michelle, how long have to stop a P p i before checking a gastro novel? Eso I'll say that's an advanced question. I'm glad to see that folks are aware that the PP ice caused hyper gastro Neemia eso, I would say typically, Um, if you're you have to be first of all, very sure that this is not a gastronomic patient. You don't want to have somebody be on P p I with a gastronomic and then withdraw the PP that could really lead thio bad things in terms of preparations. Um, but in terms of, you know, if you're pretty sure that this is not a gastronome a and you want thio withdraw pp I, um, to see what the gastro level is. Um then waiting about, I would say a few weeks, maybe 2 to 4 weeks. Sometimes we have to wait a little bit longer if they've really been on PP I for a very long time home. That's a good long rest. Um, all right. Next question. All right. Question number 3, 57 year old male presents for evaluation of recurrent pancreatitis for the past four years, which has been attributed to pay increased a visa attacks that persisted despite endoscopic minor Pappalardo me 3.5 years ago. CT scans have lately revealed inflammation involving the body and tell the pancreas in a slightly prominent pancreatic duct. An m r C P is performed for further evaluation, has shown here and subsequently the patient undergoes side doing endoscopy us with aspiration of the cystic lesion, the minor propellers shown over to the right. This is food is viscous enamel ease of 25. 50 and a c e a of 5600. We should have following statements are true, Amy. Comment? Sure. Thank you. S o going through the answers. Um answer a. His pancreatitis is due to pancreas to visa. Um, PayPal. Artemis should be extended. And pancreatic dark stent placed eso first of all, bankers to visa is quite common. Not always the cause of recurrent pancreatitis. Andi, I think particularly in this patient, where we have recurrent image ing that shows inflammation in the body of the tail of the pancreas and the dilated pancreatic duct. Onda, we have the m r c p image below. I think we have to do our due diligence and look for other sources for the pancreatitis. Andi, one of those things that you could do looking at Answer B is refer the patient for a Whipple procedure we see here on the top image. Um, usin coming out of the papillon on the bottom image. The m r c p uh, in the main pancreatic duct. We seem to see dilation in that area on dso the image ing on fluid results do not suggest a branch duct. I p m n on dso Therefore, surveillance with m r C p In a year, eyes not warranted. Uh, pm men's that involved that seem to involve the main duct carry a much higher risk of malignancy on dso for therefore annual m RCP eyes Thean correct answer Andi, think for answer D ah laproscopic coal suspect me should be performed because these recurrent idiopathic pancreatitis I think with our image ing and the clinical course described here, we've actually found another source for his pancreatitis. And so cold suspect to me is incorrect. Um, that's exactly right. I believe on the next slide. AMIA is maybe the one after that. Uh oh, no, it's, uh okay, now go back. Okay, that's all for this one. That's on the next question, actually, Um, yeah, exactly. It's a means indicated, You know, tourism is common, and you really need to make sure that there's other reasons. So main duck type men and involving the main duct cause mucus plugging off the pancreatic duct. And so it's an indication for reception. I mean, as she mentioned a me too mentioned that there's much a higher rate come from malignancy. Um, in May, Doctor. I pm ent Um I know Chris has a special love for the pancreatic cyst. Um, do you have any further comments you wanna add here? Do comments, I think Never ignore a dilated pancreatic duct. Um, it is that is never a normal. You know, age related finding is, you know, maybe in the 90 year old you may see three or 445 millimeter duck, but for in general, never ignore a dilated pancreatic duct because you need to allow pancreas, cancer, pancreas, cancer, pancreas, cancer and then other things like main duct. I came in, which is a risk for pancreas cancer and then chronic pancreatitis or the main things on the other thing I mentioned about pancreas Davies and just like Amy said, it's actually quite common, and the majority of people with pancreas to visa never get pancreatitis. If you flip it around and you look at all the people who get pancreatitis in general on Leah might very, very small fraction of them will be attributed to the visa. And it seems that the one sub group of people with Davies um, that are risk for Davies. Um, associated pancreatitis. Are those that have a CFTR or cystic fibrosis? Uh, transporter mutation gene gene mutation because that affects the viscosity of the pancreatic secretion. So if you're if your pancreas is predominant, you have pancreas Davies. Um, and your pancreas is predominantly draining through the minor padilla, and then you add on top of that viscous pancreatic fluid, that's where you can get an obstructive type phenomenon causing your pancreatitis. But again, that's such a small percentage of a small sub population of people. So, um, you know, it's it's actually quite controversial. If doing endoscopic therapy of the visa in, in in most people has any benefit. Amy, can you come into a little bit about Let's say the patient gets his football. Uh, you know a little bit about the need or if there is a need for surveillance after resection for a 9 p.m. N. Sorry. Having some mute issues. Um, so e think the issue of surveillance is probably dependent on you factors. Um, one is sort of the extent of main duct involvement within within the pancreas, and you're looking thinking back on this, patients um RCP looks as if the ductile involvement goes about a third or up to a half of a way back into the pancreas. And so, you know, if we see residual dysplasia at the margin at the surgical margin, I think that is a reason to continue surveillance. Um, and many of these cysts are multifocal on DSO. There can be sporadic involvement throughout the pancreatic duct on DSO. Surveillance can be considered as long as the patient would still be a surgical candidate down the road on. But I think that's something we should always consider. I think we always look at the cysts, the cyst, the cyst. But we also have to take patient related factors into account on diff. This is somebody that we would not consider doing any further surgery on than considerations of surveillance of the the I P m n. For their all along, uh, might be managed in that direction. Um, Chris a red. Do you want to comment any further? I think that covers it. Yeah, I agree. Yeah, we all sort of forget patients out of surgical candidate. What's the point? Um, so next question, which of the following is an indication for surgical resection of an I p m n intramural modules elevated cyst fluid ce a over 500 or the common reason for coming to my clinic, which is anxiety about the presence of assist or assist size greater than three centimeters. Um, Amy, what? Your thoughts here. Uh, so I think what we're seeing here are a variety of assist features. I think if we're continuing along with our first patient, um, sort of along that theme with AIP men's what I first do is I look, um, for, you know, worrisome features right off the bat and those for our patients, um, to include pancreatitis, jaundice and other features. And so our patient already has, you know, some indication that there's inflammation in the pancreas, uh, present already, um, other considerations, as you sort of followed down the Fukuoka guidelines, which hopefully we can review. And I know we're in some of the presentations earlier, our intramural nodules on diff in intramural Nigel eyes seen within a pancreatic cyst on on endoscopic ultrasound or even Emery. And that could be an indication for surgical reception. Elevated cyst, fluid, CIA. I feel like I have Chris um, in my ear on this one. Um, the elevation sort of the magnitude of elevation of the C e. A eyes not associated with malignant potential. Um, patient anxiety about the presence of assist might be a reason for referral to Dr Nakoula, but not necessarily a referral to a surgeon on Ben for cysts size greater than three centimeters. Um, that was something that previously we have been very concerned about. Um, but now I think we have better data. So showing that assist as long as it's stable, Lee greater than three centimeters, um, can be followed in surveillance. Um, tell if you can go to the next slide. I believe the guidelines were on there. Um, there we go. You know, a uh huh. And so is Amy had pointed out, you know the area the box highlighted to pink. There. Those are these out of high risk features mural nodule, which could be something just plastic or malignant. Any main duct feature suspicious were involvement. And, well, you should say a death over a centimeter on obviously Scientology that suggested malignancy. And all of those send you down the surgery pathway. Um, there are lots of guidelines, and there's no way that the boards are ever going to test you on the different types of guidelines. But there's pretty good agreement about those things are the reasons to go for surgery. The rest of the guidelines and all the controversy is what size and how often, and forever or not forever. Um, but if we think about the big things that was going on, they all agree. Those things that are there as maybe had mentioned, John does pancreatitis. There's bad. And then these other things here, the modules may induct features and psychology That's really bad. Those don't get respected and everybody else is gonna get watched. Um, on size used to be something that we really obsessed about, but now it's just sort of makes us watch more closely, but certainly don't send. Send anybody to be poor, um, Ed or Tina Chris. Anybody else have any more comments on this or others? Just related issues. He's coming up all the time. Of course, everything that you said so far, I think the really key points to remember our obstructive John does weight loss, alarming symptoms, any solid component within the novels or within the duct really on, but the main dockside being greater than one centimeter? I think those are Those are the key features, really room to really remember that this is a high risk sign on referral to surgery should be made. And I think Amy hit the nail on the head with the cyst fluid. See A. It's probably one of the most misinterpreted tests that we see in patients with cyst. So all assist elevated cyst fluid ce a and we basically use a cut off of about 200. All that basically tells you is that the cyst most likely is amusing producing cyst, the most common music producing cysts being i p m n. But as Amy pointed out, it has zero correlation with risk of malignancy. So sometimes you'll see a cyst fluid CEO of 1000 or 5000 in a one centimeter cyst without any of these other features, and patients are getting sent to surgeons and you know all these other things a lot of anxiety. But I think that's the most important thing is it's like a pregnancy test of whether or not you have amusing assists, and that's all it really tells you E was just gonna say the great if you could pee on a stick and I will tell you if you use an assist, that would be e. A 69 year old woman was found to have a cystic region of the pancreas was being evaluated for an attack of acute diverticulitis, no history of acute pancreatitis or the pancreatic disease. And no prior abdominal imaging was performed in the past 10 years. A CBC getting camp panel, all with the normal limits. Our father died of pancreatic cancer against 58 years old. She was very concerned about her pancreatic cysts. And her physician ordered an M R C p, which reveals a six centimeter cyst in the tail of the pancreas without obvious communication to the duct, which is the following. Would you recommend to her for management of the cyst? Um, can you start us off on this little baby can describe a little bit about the M R. Sure. So here we have, um, our findings with six centimeter, which is rather large on significant assist in the pancreas. Um, there is no communication with the pancreatic duct. Um, that eyes described on De So therefore, you know, I think it's a little bit in question What type of assist we have here? Um, one. I would comment on the family history of pancreatic cancer because I think this sort of Peyton's theological mum of the patient, um, from data that are now approximately 15 years old. We now know that having one first degree relative and a first degree relatives and mother, father, sister, brother a child, um, does not seem to increase risk of pancreatic cancer. Significantly, overpopulation risk, however, having two or more family members who have been affected by pancreatic cancer, particularly when those two individuals or first degree relatives of each other and the individual that we are looking at is a first degree relative of that individual, then that does significantly increased risk of pancreatic cancer. Another question that commonly comes up is well, we have, you know, a family history of pancreatic cancer, But we also have a system, the pancreas. So do we need to follow that cyst more closely? Andi, the answer there is that we don't really know, but we do not at this point have convincing evidence that suggests that we do need to follow those cysts, which are typically side branch I p m men's, um, much more closely. However, I think in this case with this image ing characteristics, I think there's a bit of diagnostic uncertainty. I certainly would be curious if this is a mysterious adenoma on dso. Therefore, I would not recommend that she have a distal pancreas check to me at this time, since those solutions are typically benign. Um, pet scan. I think we can discuss the utility for image ing in the pancreas, but it has very limited utility, uh, in my estimation, for pancreatic imaging both for pancreatic cancer as well as pancreatic cystic lesions. Andi, I think because the diagnosis, um, is, you know, somewhat in question I think doing an endoscopic ultrasound with F N A in this situation with fluid sent for CIA and cytology may be very useful. So if we have a endoscopic ultrasound cyst fluid ce A, which is quite low, that would suggest that this may not be, um, usefulness lesion and particularly, you know, I think others can also comment on cyst fluid cytology. But if we have benign or bland cytology, or if someone eyes considering biopsy in the wall of the cyst. And we have, you know, clear features of a serious Ystad number. I think that could really reassure us on and, uh, allow the patient clear idea of her diagnosis and further management. Um, and again, I think for the same reasons, a repeat m r C p in one year is probably not the best approach at this point. Um, perfect. Tina, our ed, Can you comment any further about you know, your approach or what your thoughts are? Here s So I think there is a subnormal zehr very common in woman, like in their sixties and seventies. So this question's a little sets up for that. And a lot of patients are asymptomatic on bits, often like instantly found for in this case. So she had diverticulitis and the image there they have found it. I think six centimeters might alarms some people. I think general school of Thought used to be that anything greater than four centimeters just deserve some, um, you know, evaluation. But I think if the patients are asymptomatic and on cereal image ing, this is not rapidly growing and the U. S definitely kind of confirms that this is in fact, your sistema thes aerbin lying legions and can be watched clinically. So I think what Amy said is absolutely right. Yeah, I agree. I think the worrisome thing would be the size for this. But again, it has the classic findings on the m r. I of a seriousness that noma um, but again, given the size and given the patient's anxiety it, sometimes it's worth just doing the FN A for that basis. And then I would argue that if it comes back with the low c e A and you're pretty security diagnosis that you don't necessarily have to follow her with imaging, I don't you know, unless she develops new symptoms, I don't know what it's going to change. Other thing. Anxiety. If the radiologist says it's grown by like 0.3 centam, you know, three millimeters, then you know it's just gonna add a lot more sort of consternation on the patient's behalf. But I would argue that once you do the fn A and it tells you what you think it is in this case a seriousness adenoma, I think you just follow her clinically. I wouldn't even imager again. Yeah, great. That's very much in line with the board's answers that low CIA is super critical here. Um, you know, when these often have an undetectable ce a or at least less than five on that sort of a slam dunk for something non useless. Um, and so it's one of the really useful kind of see one of the times where ce a can really kind of clinch this, Um, you know, for the sake of time, there's more to discuss going to discuss, um, sister Well, biopsies and N c l E, but we could come back to that. I know we have some pancreatitis questions as well I'd like to get to, so it's going on to the next question. 25 year old male. The past model history of Miles Crone's disease, currently off medications, is presenting with recurrent acute pancreatitis. He denies any history of alcohol intake, and M RCP shows no evidence of biliary disease. There is a mid pancreatic duct structure and undergoes a B or C P, which shows shows the structure there brushing with the structure of land, and its labs are as follows normal calcium normal triglycerides. Normal I G four in a normal C A 19 9. Which there is the most appropriate. Um, Dr Herder. Next you can get commented all here. Sure, City. So first, I'll just comment on the sort of the overall work up in this question, which isn't necessarily the approach maybe would have taken first. Uh, you know, he's coming in with the current acute pancreatitis, no history of alcohol, and take em RCP with no biliary disease. So we'll assume he doesn't have stones. So we're going looking for another reason for his pancreatitis. Um, seeing the pancreatic duct stricture on imaging, I might have gone for an us first. Of course, he's a young male. You know, it's very unlikely that he has pancreatic cancer, but just to rule out a mass and then ultimately the diagnosis Here you may even get from potentially Unefon a which we'll talk about, but, uh, he's also, you know, doing a diagnostic. Ercp carries some risk here of developing post your CPB angry Titus. That being said, given the information we have, um, again, we have a patient with a history of IBD. He has a pancreatic duct stricture Andi, This is leading us down the thought that perhaps he has autoimmune pancreatitis in this case, Uh, given his negative i g four and the association with IBD, it's probably type two autoimmune pancreatitis, which responds very well to steroids. Eso The answer in this case is be prednisone, followed by a prolonged taper, and again, I would probably avoid any further procedures on him. The Patriotic Ducks tent is unnecessary since they'll probably respond to medications. Certainly not surgical exploration. In this case, that is, a tire print is interesting, but that's ah, maybe a second line after the Prentice own. Um excellent. Nick, can you comment a little bit on your typical symptoms between type two and type one autoimmune pancreatitis? Uh, type one? Yeah. I would expect, uh, older patient. Um, again, there's association with I G four related disease so they may have other systemic manifestations as well. Sometimes they have biliary strictures from I g four related cholangitis, um, or again other other organ involvement from my G four disease and, uh, type two. They do not have the elevated I G. For they have isolated pancreatic disease. There's association with IBD, and they tend to respond very well. The steroids. It's very unlikely that they relapse. Actually, in type two, you know the type one. Probably a half to two thirds of patients respond, but sometimes they need a second course. Type two. They tend to respond very well to the first course. Uh, excellent, Chris, I know your true love is actually autoimmune pancreatitis. So you know, any any insights you like to share This can be confusing. So can you kind of make it a bit more straightforward? Yeah, I think just toe playoff of Nick's, uh, great responses is Type one is typically presents, like pancreas cancer. It's older men on these men, these patients. Sorry, sorry about that. I was saying Just the playoff of Nick's thorough answers. I think type one type one type presents like pancreas cancer. These air older men who present with painless jaundice they may have a mass on image ing or, classically, the sausage shaped pancreas. Um, very responsive to steroids, typically don't even need a biliary stent for their John just to go away. Type two is a different animal. It's younger patients with men and women being equal, and we're talking patients in there, I would say late teens or even younger. I mean, we just saw a kid who's 13 with this, uh, but more common in Children and young adults, thirties and forties. Um, but typically not the painless John Doe's picture. It's more of Ah, Hank, acute pancreatitis, recurrent pancreatitis. Or, I think, what we've seen in cities. I know you and I have discussed this all the time this morning, like smoldering pancreatitis, they get in attack, they never really get better there, you know, in and out of the hospital. And, you know, they never quite resolved after their first attack. And it's not until they get diagnosed or put on steroids that they get better immediately. But it's two very distinct entities. Um uh, that to keep in mind now. Well, the one thing I'll say without droning on and on is just most of the time an elderly person who comes in with painless join us in a bank masses gonna pancreas cancer. But a subset of those patients who may have a negative biopsy for cancer. That's when you need to start thinking about autumn. You pancreatitis. Chris, A very, uh, thoughtful and difficult question from the audience is what's the role of F n A or FNB for autumn pancreatitis when you can make a presumptive diagnosis a great, great question, and again, we debate this all the time. I think for type one, if you have a classic sausage shaped pancreas on image ing, if you have an elevated serum I g four. I think you can go ahead and presume that patient has automated advertising. Can treat them with steroids, monitoring them closely for resolution. And you can do that without a biopsy. On the other hand, type to automate pancreatitis. You need histology to make that diagnosis. And again, we debate these cases all the time here. Um, my personal feeling is that if you have a patient with suspected auto mean pancreas type to automate pancreatitis, a U. S. Guided core biopsy is safe, Um, and very high likelihood of giving you the diagnosis or ruling it out. What happens is if you don't if you suspect type two and you don't have pathology and you start putting these patients on steroids if you're if that's an incorrect diagnosis, you go through this whole vicious cycle of steroids on and off while my pain came back. Is it my auto mean pancreatitis? And you sort of You're a dog chasing its tail. You just never know if that was the problem to begin with. Um, So we're actually studying this right now to try to identify what are the EU s features that are highly highly correlate with the presence of on a mean pancreatitis so that it would give the practitioner more confidence in doing a biopsy? Or that they can safely say, You know what, they don't have any of these criteria. Maybe this is an automated pancreatitis. Let's look for an alternative diagnosis. But but I do feel strongly that if it's suspected in type two, a biopsy is safe and highly diagnostic. Thank you for that before we sign off. I just wanted Thio asked Nick to comment real quickly. Just about the role for antibiotics in the initial, you know, week of acute pancreatitis. Patients come in temporal sick sometimes, you know. But in those 1st 57 days, you know what your thought about giving people antibiotics? Sure. I think this question comes up all the time because acute pancreatitis can present with a serves picture, and sometimes it's tempting to think that those patients are septic. But really, it's just the inflammation from the pancreatitis, which you could drive fever, tachycardia and look very similar to infection. Uh, the important thing to note is that it's very unlikely that the patients were infected within their acute presentation in the first week or so. They haven't had really had time to develop the local complications that might lead to infection down the road, such as an acute Perry pancreatic fluid collection or acute and chronic collection. So I would say in the initial presentation initial week antibiotics are not indicated. Uh, if the patient seems to be getting better, and then after a week, maybe they spike a new fever, then I would be concerned enough to consider repeat imaging and look for actually an infected collection or another source of infection. Perfect. It's tough to remember clinically, but it's really important. Remember the time course of these things? But if I know for the questions from the audience, I just want to thank all of our Panelists for joining us today for a lively discussion. Um, is there any other, uh, if the audience has any other questions, feel free to email. Any of us at any point would be happy to sort of answer your questions. Thanks everybody, and we'll see you at our next Q and A. Have a good night. Published September 29, 2020 Created by
