Video Endoscopy Conference 4/2/21 Play Pause Volume Quality 1080P 720P 598P Fullscreen Captions Transcript Chapters Slides Endoscopy Conference 4/2/21 Overview Three cases presented here: 00:00 Intramural Duodenal Hematomas 14:11 Gastric Ulcers 28:45 Necrotizing Pancreatitis, Part I I have an interesting case from a couple of weeks ago that I'm going to present that I saw with Dr Stein Law and the advance team was somewhat involved as well with an interesting complication. So essentially this is a 71 year old. He actually has no past medical history. He presented to Lenox Hill with shortness of breath and there was concern for covid infection. Had a pretty significant work up was found to have bilateral pleural effusions. He had like four negative covid swabs in extensive work up that ended up diagnosis of a, He had got a diagnosis of plasma cell leukemia and he was transferred to Sinai for further work up and care. When he got here he was started on direct. Um Ahmad, he developed worsening shortness of breath. He ultimately required transfer to the ICU intubation. All this was thought to be a reaction to the artemis mob. However, while he was in the ICU he developed Melina and we were called, He was he aerodynamically stable. This occurred over a weekend. However had a three g drop in his hemoglobin. He was not on any systemic anti coagulation and his labs at the time he had a hemoglobin of 6.5 from around 9-10. His platelets work 40. He had a normal white count at a normal essentially normal iron are. So monday morning came around and he was planned for an E. G. To evaluate for a source of bleeding. I did keep the labs in terms of platelets and hemoglobin on all these slides just so we know in terms of the timing of the scope because it will become relevant. So his platelets on the day of the E. G. D. Or 64,000. So initially when we did the endoscopy we saw a large amount of blood clot in the oral pharynx. You can see this, you can see the the cords and the first photo on the left and this like tonsils or hematoma on the right side. When we got into the esophagus it was normal. The stomach was normal. However, when we got into the duodenum and the bulb we saw this large ulcer and with a little bit of lavage it had active bright red blood. So we thought that this was the source of his melon and his hemoglobin dropped. The tissue appeared pretty thin and friable. So we were pretty cautious. We did not think that there was an area we could get a clip on in terms of so large, we didn't really see an area where we could get normal tissue to grab onto. So we emptied it in four quadrants and then used a goal a probe to treat it and I'll show you what it looked like after. So this was the after we thought we had good hemo stasis. I will say we were a little bit cautious and we're planning to do less than more because of how thin the tissue appeared and felt. And just a note. He had a normal duodenal sweep and you can see the second part of the duodenum there it's widely patent. So he's returned to the floor without any issues. And during the day after that during the day of the E. G. He was completely stable the next morning he was found to be pretty hypotensive Like 70 systolic. He's actually started on some pressers goes back to the icu. He had one episode of Melania that morning which we weren't too surprised about given the amount of blood we saw when we did the initial scope. But he did have a to ground drop in hemoglobin and given the drop in hemoglobin with the hypotension. We talked with advance about whether or not they thought they could get a clip on this because that was the one modality we did not use. And in the setting of the low platelets, we thought if we could get mechanical closure it would be better. So the plan was to bring him back. We thought that he was bleeding from the same duodenal bulb ulcer. And the plan was to bring him back for a romesco over the scope or bear claw clip. So on the second endoscopy we got in, he had the same oral fragile hematoma. The duodenal bulb ulcer actually looked great. There was no active bleeding. We could no longer see a visible vessel. However, what was notably different about this case was that the dude in the second part of the duodenum, we could not get through the sweep as you'll see here, the wall is really adam entous. It almost has this purplish hue to it and it was incredibly tight. We tried to get through, we needed materials help to get past, ultimately able to traverse, but it was pretty tight. And just as a comparison, the endoscopy zor two days in prior. So this was monday's second part of the duodenum and this is Tuesday. So because of this, there was concern for an RP bleed. So he went immediately for a cT angio, which showed in the descending duodenum, a large heterogeneous fluid collection concerning for an intramural hematoma Measuring eight x 5 cm with fat stranding. And there was no RP bleed. So I thought I talked briefly with this was the first time I had ever seen this happen and we were all pretty surprised. I thought I talked briefly about intramural duodenal hematoma as a complication of endoscopy. So essentially I found a couple of case reports. There isn't much in the literature as you'll see very quickly. This is an incredibly rare event but essentially there so they're very rare, minimal literature except for these couple of case reports which I had and what it seems is that judy. NoWell hematomas can present in patients who had a normally G. D. With no intervention. It can be seen in those who had duodenal biopsies. And it was also reported in those who have therapeutic injections into a junior dino ulcer. Majority of the cases in the literature that I saw were in patients with any underlying clotting disorder, systemic antica regulation those with leukemia and those who had a bone marrow transplant. The incredibly rare. There were cases where there are patients who didn't have any duodenal intervention. So no biopsies, no thermal therapy. And the thought was a cheer force of the endoscope on the duodenal wall as it passes through the sweep could cause a hematoma in somebody who is at high risk. And this was thought to occur in the setting of the fact that the duodenum is relatively fixed in position. It's retro peritoneal and has a pretty rich vascular supply So this can happen. I just want to point out I looked out there 70 million E. G. D. S done in the in the U. S. Each year roughly. And so this is an incredibly rare complication. The majority of the duodenal hematoma is described in the literature presented with obstructive symptoms. So nausea, bilious or non bilious. MSs inability to tolerate pio. After the endoscopy, there were a couple of patients who presented with abdominal pain. I think it's important to rule get cross sectional imaging and rule out an R. P. Bleed as they can kind of present. Similarly both clinically and endoscopic li see extrinsic compression, discoloration drop in H. And H. And hypotension. Which is all the things we saw in our patient. So no one standard intervention for duodenal wall hematomas. Post endoscopy. Almost all of these patients improve with conservative management after N. G. Tube suction and pio fluid repression. TPN if it's prolonged there was no clear role for IR or surgical drainage. Um The the team had called us multiple times to ask about draining this hematoma. We left it. There was a case report of a patient who developed biliary ductal obstruction and then one other case of a pink duct obstruction secondary to the size of the hematoma. But again both of these resolved with no intervention. They did note in some of the literature that the surgical intervention is reserved for those obviously who developed a perforation, fistula, bile duct injury. Um Some of the there's one case report that noted that you should intervene if the symptoms of the obstruction last for more than 7 to 10 days. But others just argued that just leave them alone and with time this will go away. So back to the our case just very briefly our patients started on TPN. The team manages and Youtube to suction. I will say it's completely clinically obstructed at this point. Which was not the reason we went in for the endoscopy but that became very apparent 10 days after the second endoscopy they clamped the N. G. Tube however became very nauseous. He was vomiting abdominal distention stick with the N. G. Tube back to suction about 20 days after the endoscopy. He actually was able to tolerate the N. G. Tube clamp trial and he's currently being trialed on clear liquids and remains on TPN. So just very briefly in terms of complicated conclusions. Duodenal hematoma secondary to endoscopy are incredibly rare. Intramural hematoma is a curse. You usually occur in patients who have had to latino biopsies, injection or thermal therapy but you don't need to have these interventions mostly seen in patients with underlying clotting disorders which makes sense or a systemic anti coagulation leukemia. Usually symptoms are obstructive and just to note our patient presented with less with obstructive symptoms and more with hypertension and a drop in their hemoglobin and that's it. That's a nice case stuff. Thanks so much. I think you know we probably see or experience hematomas more than we we realize. Um I mean this this case perfectly demonstrated what the literature shows as far as, you know, the risk factors in this patient. But I would I would argue that most of us have seen a hematoma after putting a peg tube in and we certainly see it. After doing us guided needle biopsies, you'll either see the hematoma form outside of the stomach or duodenal wall between often with the pancreas, or if your biopsy just just in particular can be vascular. Um And it can be kind of a harrowing thing when you're witnessing it happening because you feel helpless. There's not really much you can do. Um My experience knock on wood has been that most of these are just self limited and typically will just observe them as they form. I have this voodoo theory that if you distended the loom in it may help Tampa nod the vessel. Um And you know, obviously the patient is having pain or hypertension or something than something more urgent. Such as embolization or surgery may be needed. Um Did you come across any recommendations or cases where these hematomas were able to be evacuated? Either per cutaneous lee or endoscopic lee? I didn't see it looked endoscopic li I didn't see anything. I did see I think one case report where I. R. Had drained um The dude you know what hematoma And it had been It had been there for I think 12 or 14 days. The patient is still clinically obstructed. So they sent it didn't sound like a change management and the case report didn't seem to think that that was necessarily the you could have just waited was the idea if it's a big clot clotted hematoma. I don't think putting a drain is going to help anything. I've seen case reports of endoscopy is using temporary stents and other measures to sort of temporarily bypass the situation. And I mean clearly these patients can be obstructed for weeks at a time which is not great. But one interesting, I agree there's no role really for drainage. One interesting thing about our patient which we kind of hemmed and hawed about was that he had Platelet count over 50,000 when this happened. Not on any systemic anti coagulation. Whether those platelets are functional, I don't know. But at the end of the day he didn't have a he didn't have a platelet count to 10 that we kind of took him anyway. So the fact that this happened was interesting. Yeah, I guess I have a question on those lines. Um is there any sort of thoughts or recommendations regarding like if you're going to inject something like a pay um about like whether you shouldn't have to, platelets are a certain level or whether you should give platelets or something to prevent something like this? I mean, I guess it's so rare that I think probably isn't any clear recommendations. But would you be more hesitant to give epi um in this setting? Because of the low platelets? I don't know if anyone else has any thoughts. I don't know if it's very clear. I also don't know if this occurred from the epi injection or from the thermal therapy. Like, I'm not sure what the inciting event was here jerry. Have you seen this? Have you come across this in your career? I've seen one duodenal hematoma and it resolves spontaneously. Of course, in a patient with uh oh, it's extremely low platelet count. Like this Stephanie did his platelet count come back up now that he's off chemo as platelet count. He's actually, they're still giving him chemo. Um So his platelet count has bounced around but it's I think in the seventies or eighties 1000 range now dr katz. Any any comments on case like this? Not really just patients higher from Jerusalem wow. Hey Chris can I correct one quick thing? It's not really a correction but stuff just so that's not sitting out there in everybody's mind. So the volume of you know, endoscopy and colonoscopy in the country um 75 million has been thrown out as all the endoscopy is that include like Bronchus copies and urologic procedures and stuff. It's okay. The colonoscopy volume in the country's somewhere between 15 and 20 million a year. And the upper endoscopy volume is probably more like 10 million years. So it's more like 25 million. It's okay. I just don't want you to go away thinking it's the first thing when you just google it but it's too high. Oh look who's here Lucas? Who's joining us today? Thank you. T Lucas say hi say hi to everybody. All right. This could never happen in the hospital. It's so good Lucas unfortunately didn't finish his power point last night. So um I think unless there's other cases we'll move on unless those other questions or comments we'll move on to june. Thanks so much stuff. That was a great case. Mhm. Guess luck looking through with that look see and you're on mute. Am I am I on presenter mood? You're in presenter mode and now we can hear you. It's all good. Is that better? Much better? Okay. Um All right so um good morning everyone. I have a case to present me that I saw actually just this week at the V. A. All right. Um So this is a 72 year old gentleman with a history of alcoholic and hep C. Cirrhosis had spr with treatment. Um Besides hepatic encephalopathy thrown beside opinion His mouth sodium scores 24 and that has been stable. He's presented to E. D. with sudden onset of the gastric pain lasting about 4-5 days. Had tried some pepto bismol and ibuprofen after the pain started. Um With no improvement. He had some dark stool against after taking the pepto bismol. His laptop was 3.8 on mission. His life base was 43. His Cbc and CMP were stable. He had some mild elevations in the trans Am ministers that he had previously. His billy was around five again around his baseline. Um and as he made 11 was 12 on exam. Um He was joined us distended. Um Have a descent abdomen which was soft but tended to palpitation and the epic gastric area. No guarding rigidity. Um And he had asked your excess, although he didn't appear overly confused. His abdominal ultrasound showed cirrhosis called Earth ISIS, but no doctoral dilation. He had patent vasculature. Unfortunately, he didn't have any safe pocket for diagnostic paris. And he says I was treated empirically with IVF try oxen for suspected spp. But unfortunately continued to have severe epic gastric pain despite three days of antibiotics over the weekend. Um So we decided to get a cat scan. And these are some representative images. Um If you can look at a stomach um it's here and you can see that there is some irregular wolf thickening but you can see. So we decided to do an endoscopy. And this was what we found. Um He had a lot of old blood um using on irrigation from this large gastric. Um Also it was Henry circumferential surrounding the pie loris. The high lorises. At 6:00 on this image you can see that has irregular raised borders, some areas appearing very polyp oid got very necrotic base. Um And then once we go into the pilots there's another two ulcers. One of it you can see on this image, it's at 11 o'clock in the Georgina bulb and one through this area here as well. Again with necrotic appearing basis. So today I just wanted to spend a couple of minutes talking about gastric ulcers, a malignancy. Um 5-11 of gastric ulcers are mulling according to literature. Um gastric adenocarcinoma is much more common than film or metastatic cancer. The major risk factors as we all know or h. pylori and instead use for gastric ulcer. Also smoking increases the risk of gastric ulcers by 2-3fold. And heavy drinking increases your risk of bleeding ulcer by fourfold from baseline. Um And this cop IQ features have been reported as irregular shape, hollow point or rigid aspect of the border of the also irregular elevated borders and necrotic base and also size greater than two centimeters. There are no you know um strict definitions of what malignant appearing ulcer is that is used across the literature. Um In terms of current practice. Um Since malignant ulcers can present with a benign appearance and biopsies can miss malignant areas. Prior recommendation has been to follow up or gastric ulcers with serial G. D. For healing. Um But there's been a lot of questions about this um given the low incidence of gastric cancer in the West in terms of clinical outcomes and cost effectiveness. So these are the current HSG guidelines for the role of endoscopy um and the management of patients with peptic ulcer disease. I picked out two recommendations. Um They recommend that biopsy at index endoscopy should be individualized and this is based on low quality evidence. Most gastric also should undergo biopsies because Molina also is made appear endoscopic benign. However they say that in some clinical situations such as young patients taking and sets multiple benign appearing ulcers which are kind of shallow. Um And in the Antrim the risk of malignancy is very low. So you may opt not to biopsy at that point, as she also recommends that surveillance endoscopy should be individualized again based on very low quality evidence. Um They suggest follow up E. G. D. And patients who remain symptomatic despite an appropriate course of medical therapy in patients with gastric ulcers without a clear etiology. And patients who did not undergo a biopsy of the index E. G. G. Which is very common given that oftentimes we do this for beating. Okay. Um I pulled up a couple of studies on which this guideline is based. Um firstly. Um This paper in the Journal of Clinical Gastroenterology. It's an old study but it's a very large study. Um It was done 90 92 at Duke University 1189 undergoing gastric ALs with gastric ulcers on a. G. D. With biopsies obtained almost 500 patients. They found 4% which be malignant. And um the altars were classified as benign versus malignant based on endoscopy. Ist impression. Um The sensitivity of this endoscopy is impression was 84% with specificity of 0.9%. Um 130 patients out of this cohort underwent serial G until healing. And no malignancies were found during surveillance and estimated that using Medicare reimbursement one early detection of gastric cancer would cost $150,000. Um So it seems like our endoscopic impression is pretty good. And um serial E. G. D. Doesn't appear to make much of a difference in this case. This was spanish study again very similarly structured. Um this was done in 2002 in the same journal. Um 529 patients. The gastric ulcers on and uh G. D. Um and the ulcers are classified on appearance, benign malignant and inconclusive. 330 patients had biopsies taken 12.4 being malignant and um sensitivity was 82% and specificity 95% of our endoscopic impression of malignancy. 117 patients completed follow up in this study and three new malignancies were detected in these patients. All of these patients who had malignancy detected had an inconclusive appearance at the index endoscopy. So inconclusive gastric ulcers on appearance. So neither groups defined h pylori presence. Um Apparently in the Duke study at the time point in the nineties, it wasn't routine to put that on gastric ulcer biopsies. And I wanted to point out the difference in the rates of malignancy and four versus 12%. So it's quite variable. So in my quick literature search, I didn't see uh my quick research, I also found other potential risk factors for gastro, also malignancy, giant gastric ulcers where the three centimeters had a 37% chance of a rate of malignancy. And one of the papers I saw they also location including in Missouri cardio funders had a greater rate of malignancy than the Antrim patient age. Um And then also I wondered whether geography, ethnicity might play into this. Um, this, I didn't find a Michaelis church, but I wonder whether this is something that we should because remember recommend surveillance. We are having more us conversations about castro cancer appears to have a testament to pleasure, for example. And since the guidance do leave guidelines leave us a lot of leeway. I wondered if our police would share their decision making in the process of recommending surveillance, whether the size, location and whether you take into account any kind of ethnic background or immigration status. Um, in addition to your more classic gastric cancer reflectors, thank you. Oh, so I may have missed it. But what was the result of this patient's biopsies that is that is to be determined? This is Moscow p done on Wednesday. So, um we're still waiting the path. So the other, the other point I'll make and then we'll open it up to questions is traditionally I mean I hate to say when I was a fellow but when I was a fellow the other indication for a recommendation for doing a follow up endoscopy and patients with ulcers was if they had what was considered a complicated ulcer meaning it was either bled or caused obstruction or perforation. Um I mean in preparation assuming they're going to the O. R. But that was the other indication to do a repeat endoscopy after eight weeks of acid suppression and then the other the other I was curious if you came across anything. Um uh Well I guess you mentioned in this first one. Yeah the multiplicity multiple ulcers also is unlikely to be a malignant. It's more of a big solitary one that you worry about. But I see I see that in the first recommendation here young patients within said with multiple benign appearing also. Typically those those are not malignant. So we'll open it up for any thoughts or comments your husband stand up. Uh You mentioned in your presentation that one of the reasons that people didn't take biopsies at the time of upper endoscopy was that there was bleeding. Do you do you agree with that based on on your review if you see an ulcer? Uh There's there's lots of reasons to take biopsies for example, to see if there's hpai Laurie is one reason why why would it be inappropriate to take biopsies? Um It's not so much that it's inappropriate. It's just what I've seen in the studies that I outlined the reasons for not taking the biopsies retrospectively seem to have been bleeding. Um I think that we should I think after reading the literature or guidelines I think it would be much more inclined to biopsy patients than not in this case. Peters points well taken. That comes up a lot and we do a ton of endoscopy for bleeding and a lot of times we find ulcers. And somehow the lure is that they're somehow, you know, you shouldn't biopsy that because it's bleeding or if the biopsy causes bleeding, you won't know. But I mean honestly, how many biopsies do we do bleeding is not really a major concern in general with biopsies. And you know boy, there's there's some yield in by up seeing some of these funky things that we may see in the stomach. Or where else? Where I agree with Peter Kill seems to have his hand up to chris I don't know if you can see that nick. You go ahead. Okay. Yeah. I just wanted to address your your point about um ethnicity and geography. You know the studies that you show. One was from Duke and the other was from Spain. But I suspect if you did those same studies in countries where there's a higher incidence of gastric cancer like japan or Korea Russia, even certain parts of latin America you would you would find varying degrees of incidents there. So I do tend to individualize it for the patient. Um You know not only just based upon the characteristics although it's sometimes hard to um you know to to see malignant appearing features on E. G. D. And you know we I do subscribe to some of the stuff that chris talked about earlier in terms of complex ulcers. But if there if they do come from a part of the world where there's a higher incidence of gastric cancer I will have a very low threshold to to bring them back and reevaluate, Especially if the biopsies on the initial go around were non diagnostic, just because of the local potential rates of cancer there. I want to thank you in the older literature. The consideration was that when you, if you're going to biopsy gastric ulcer for carcinoma, you need to take at least eight biopsies in order to be sure that you've gotten the diagnosis. So I think that it's important not to just take one or two biopsies. You have to biopsy the edge of the ulster as well as the base of the ulcer in order to be sure that uh that you've, you've gotten sufficient tissue for the pathologist who to make the diagnosis of malignancy or benign ulcer. And tonight just as a follow on from that, is that eight passes or eight fights. That's eight bytes. And and the kills comment was following from juha wang's grand rounds a couple weeks ago basically, you know, saying that the United States is, although a quote low risk country for gastric malignancy were really a country um made up of many different sub populations and some of the sub populations in this country are clearly at much higher risk. So individualizing the approach is the right way to go and you'll see more about that in coming years I'm sure because there's a trend to make this into some sort of a guideline in the United States. Mhm Okay. Great discussion, great case. Always find something interesting to talk about on every case we see. So uh thank you so much. Gene for that thorough, thorough evaluation and analysis. Um I believe nick is on and for our final case of the morning from advanced, we'll hear from advanced endoscopy right? Mhm. Uh this is going to be a series of cases necrotizing otitis I'm actually just going to present. I'll keep it to like a series of two. Although we have a patient, I think we're at 10 plus neck respect me. So I won't make you sit through all of those. Um, so here's the first initial presentation. Uh, this patient is a 58 year old female history of alcohol use disorder presenting with a severe abdominal pain. She was initially tachycardic um with Lucas psychosis, very elevated light base and a lactic acidosis and pretty like a little higher than usual hemoglobin. Nguon as well. On imaging, she had evidence of pancreatic necrosis. You can see the areas that the arrows are pointing to. That is a non enhancing area of the pancreas indicating a lack of blood flow and necrosis. Ists. She was diagnosed with acute advertising pancreatitis secondary to alcohol and admitted to a step down unit. She got a very high rate of fluids as is appropriate. She got three leaders bullets and then to 50 CCs an hour of LR. Her diet was started as soon as we could. As soon as she was would tolerate it. I believe she was started on antibiotics which we don't usually recommend for acute pancreatitis and then it was rapidly discontinued I think once the team became um although a week after presentation she developed and so she was scanned again and she was found to have an acute necrotic collection with suspected infected necrosis here. So she was again started antibiotics. She actually stabilized with just antibiotics, no sampling or drainage and then she was discharged. Unfortunately she came back about 34 weeks later with her current abdominal pain and vomiting. And this acute collection had organized into walled off necrosis. And so then we were consulted again for drainage of this infected walled off necrosis. So we proceeded with endoscopic ultrasounds and what you can see here. It actually is filling almost all the screen. It'll zoom out in a second. Is this sort of heterogeneous collection of mixed fluid solid components here. Um that is the Necrotic collection. So it's measured out, it's eight cm across and five cm and other dimension. And then the important things kind of scroll through. You see some solid components, some fluid components. We're planning to use aluminum posing metal stent here to drain it. So the important things to measure are the runway for deployment. We usually need about six cm. This was about a little more than five which we can kind of work with. And then the other thing is the distance between The gastric wall and the edge of the cyst here, the aluminum posing metal stent Emily has a length of a centimeter between the flanges. And so this was nine estimated uh in distance between the wall and it says this is very close to the wall. So we weren't too concerned about that in this case, but you want to make sure the system that stent is going to fit there too. So this is the deployment, it's a hot system. So electric Qatar used used to puncture into the cyst. This is a catheter that the stent is loaded on the distal flanges of the stent is deployed within the cyst here, you can see it opening up. Uh then that is retracted and the goal of that is to oppose the wall of the cyst and the wall of the stomach and then under tension here, The more proximal phalanges deployed in the scope and then pulled back. And then this part is always a little hairy. So she had a lot of fluid in the cyst. So you didn't really see the deployment of the proximal flans because all we see is this particular fluid flowing out, which is what you want to see, indicates that we were successfully insists and about 300 species of fluid. Um This is a 20 millimeter axios. It's not fully hoping yet. We didn't dilate or do anything on this initial procedure. Think we dilated, but we didn't do an echo second. So we did. We dilated it open a little bit in order to fit double pigtail stents in. So as you appear in, you can see that yellow is the necrotic material within the cyst. So there was again both fluid and solid components. This is deployment of these pigtail stents and that allows the sort of prevents the edges of the stent, which are a little rough from rubbing against either the gastric or the cyst wall and causing bleeding. And that is the first procedure. This is all present today. Uh more slides here. Okay, so this is the Flora Skopje image. At the end of the procedure, we placed a nasal can't see your slides. Oh, they stopped sharing had. Okay, we're back up. So now you can see the signs. This is a fluoroscope E image of the end of the procedure. The pink is the nasal vaginal tube. The blue arrow is the lumina posing metal stent and the yellow arrow are the double plastic pigtail since. Mhm. So again, there are more parts to this in the future. I think today I just wanted to talk about uh basically the local complications of acute pancreatitis, per the revised Atlanta classification. This slide sort of breaks down the different things that can happen in pancreatitis. On the left hand side of the slide is interstitial pancreatitis on the right side is necrotizing pancreatitis. And then we have early and late complications on the top of the line. So first with interstitial pancreatitis early they can have, the patients can have acute perry pancreatic fluid collections late The late complication of interstitial pancreatitis after four weeks is often pancreatic pseudo cyst. And then in necrotizing pancreatitis. The name for the early complications of acute and chronic collection as we saw. And then late complication is walled off necrosis. So in acute perry pancreatic fluid collection is again an early complication of interstitial pancreatitis. It's just a collection of fluid, it's ill defined. It's not walled off. It may have pancreatic enzymes and it just results from inflammation or potentially rupture of a peripheral Dr. branch develops in 30 to 50 of patients with acute pancreatitis. And this is not a two concerning finding they usually remain sterile and they regress spontaneously and there's nothing to do procedurally about them. Over time, a certain percentage of these patients will develop a pancreatic pseudo cyst. Uh It is a suicide with this well defined wall but only fluid in it that helps differentiated between suit assistant walled off necrosis and it rises from disruption of the pancreatic duct. These do not necessarily need to be drained. They only need to be drained if they're symptomatic with pain infection or if they cause gastric outlet obstruction or biliary obstruction. Endoscopic drainage is comparable in outcomes to surgery with potentially a decreased length of stay acute necrotic collections are the early complications of necrotizing pancreatitis. This is a collection of mixed fluid and solid material arising from necrosis, of the pancreatic Brinkema and the surrounding tissue. Early on, it can be difficult to distinguish from an acute perry pancreatic fluid collection, except you can sort of imply that if a patient had necrotizing pancreatitis, they're probably going to develop an acute necrotic collection, as I mentioned before, and this is about 33% of patients with pancreatic necrosis develop this complication. This management depends on whether the again how symptomatic the patient is. If there not acting infected, it's probably a sterile necrosis and they don't need anything other than conservative management and observation. If they have fevers and indication of infection, empirical antibiotics are appropriate. As this patient received, we do not necessarily need aspiration to guide antibiotic therapy and then what our patient eventually developed into was walled off necrosis, which is late complication of advertising pancreatitis, which is fluid and solid mixed material and similar to a suit, assist. These don't necessarily need to be drained unless they're infected. They're causing gastric outlet or biliary obstruction or there's other evidence the patient is not doing well. Maybe they can't eat, they're losing weight. They're not getting better from the pancreatitis. Which is sort of this persistent on wellness state and optimal drainage for these has been repeatedly shown to be minimally invasive. With IR or endoscopy there's a reduced risk of complications compared to surgery and a reduced length of stay. And we will go through the data a little more in detail on the next part of this series on some of the studies about management. All right. That's a summary of sort of that Q camp local complications of pancreatitis. I think it's going to add. That was great nick and I thank you for only showing part of this. I think in the past few years our attendees have gotten a little bit of a fatigue from watching all these uh fluid collection drink. I think I'm gonna show one Niagara Stephanie, just so everyone knows what it looks like. But I won't belabor the point I want to make. I want to make two quick points. Um One is that Uh and this was a nice example of it. You're not going to see this on admission. So when the patient presents the emergency room, you will miss necrosis and fluid collections on that initial scan. It will take at least 48-72 hours for these things to evolve. So usually you start thinking about this. If your patients deteriorating their work, their course is worsening developing fevers, that sort of thing. And that's where we need to think about repeating imaging to look for these complications. The other point I'll make for I open it up for some questions and comments is that of all the things we do in interventional endoscopy. You know this is I think one of the procedures or diseases that there's been a true evolution and revolution in the management of it from primary surgical to now primarily endoscopic with or without IR drainage. But I will say and I know I can speak for the rest of the team is that it's not uncommon that when we get consulted our job is really to calm down the consulting team, the medicine team, the surgical team and the ICU team. Because more often than not the key to this is patience waiting and often not doing anything other than supportive care. Um And one of the most impactful things we can do in a patient with necrotizing pancreatitis is central nutrition putting in an N. G. Tube or an N. J. Tube and feeding them. Because there's you know time and time again. There have been multiple prospective randomized studies that show that central nutrition compared to TPM has a far better outcome in preventing infection of sterile necrosis, preventing organ failure and just having an overall better course for these patients. So it's very interesting. This is always one of the sexier things that we show and do. But more often than not we're doing nothing and just sort of guiding and hand holding. And oftentimes the initial management is central tube central feeding tube placement. I'll open it up to the audience. I think that one other area with acute pancreatitis that in addition to the central feeding is appropriate aggressive I. V. Fluid resuscitation. Um Oftentimes when we get consulted we're sort of already behind the ball. Between the er and um the admitting team. You want to have aggressive uh I. V. Fluid resuscitation ideally within the 1st 24 to 48 hours to um to have an impact on that patients care. And um I think things will also get better down the road. Are our team led by chris is working on a pancreatitis pathway. Um That will be in work in conjunction with the E. D. And the medicine teams to try to help streamline things for consulting services and for gi mm. Also give a quick shout out to Chris who was on an egg to um paper uh that talked about sort of a clinical practice update with for necrotizing pancreatitis thing was published last year in gastro. Um with some great recommendations for neckties appendicitis. So that I'm sure you probably talked about next week when you show the necrosis economies. Yeah, this is the beauty of this at Mount Sinai is that there is an artist and I think one of the most fun things about working with Nick, eel Satish and nick is that we're all on the same page when it comes to management of this. And it's so rewarding when we sit down as a group and review these cases, how you see, everyone's nodding their head when someone is speaking and sort of making their initial assessment. Um because we all we get it, we unfortunately were fortunately see a lot of this here and I think we're really proud to take care of these patients because it is one of the diseases that can have devastating outcomes. But you know, we follow the guidelines and we have the ability to do the endoscopic interventions. So it's it's a true team approach. We approach this to the family as a team. The family's always get to know all of us. And it is I think one of the more rewarding diseases that we get to take care of. So Julian and Peter both had questions and it's like a to one also. What what's your what's your theory about why they do better within terek than parental feeding? It's not a theory. What happens is it maintains the gut integrity. And because when you're in this cattle bolic state you have a decrease of your gut barrier and there's a higher risk of bacterial translocation. So T. P. R. Interval nutrition will maintain the integrity of the gut barrier and will decrease bacterial translocation. This has been shown. And to that point there's been studies that show if you give these patients probiotics, they actually do worse there the higher risk of infected necrosis. So so there are amazing studies and maybe nick can show these one day of prospective studies comparing Uh internal nutrition verse TPN and the outcomes are markedly different. I mean 40 death rate versus 20 death rate. Things like that. It's it's it's truly amazing. Yeah, you're absolutely right decision friend. And actually we should we should push much more terrible nutrition in hospitalized patients as compared to G. P. N. Also, you know, you know, IBD patients and so on. TPN should be kind of reserved for patients who are not amenable to Ontario nutrition and everything you said about transportation and so on. I completely. Which is has been very well shown in the experimental models as well. Any other last questions? I was on call last weekend and I came across a patient in the who had a NATO cystic too. I was wondering if you could comment on like that? Yeah. The use of the narcissistic McKeel. Do you want to comment? I think you probably put that in. Yeah. Yeah. Let's talk about that next week. But the when we do not protect me, if there is very dense uh necrotic tissue by putting in a narcissistic tube and irrigating it helps soften it up. It makes it easier for debridement sort of like a like a generally just flushing. But um I think when nick shows part two um and we talked about necrosis ectomy, we can have a deeper discussion into narcissistic tubes or irrigating through ir drains as well. Thank you. Right. Published April 22, 2021 Created by Featured Faculty Stephanie Gold, MD Internal Medicine Icahn School of Medicine at Mount Sinai