0:00

Okay.

0:01

Let's dive a little deeper into pancreatitis

0:03

because it is such a common reason why

0:05

patients come to the emergency department.

0:08

We're just going to go over the

0:09

revised Atlanta classification here.

0:11

We have our two cases that we just went through.

0:14

We have our interstitial edematous

0:16

pancreatitis here on the right.

0:18

That's about 90 to 95% of patients, thank

0:21

goodness, because most of those patients,

0:22

their pancreatitis resolves without a lot of

0:24

complications, and you know, you treat the gallstone.

0:27

Should the gallstone be the problem, maybe you would

0:29

treat any other underlying abnormality, if at all

0:32

possible, of why that patient was getting pancreatitis.

0:36

Now the problem is the five to 10% of patients

0:39

who have necrotizing pancreatitis. Once you

0:43

will have a portion of your pancreas die, the

0:45

duct is now left kind of floating by itself,

0:47

and there can be a lot of problems that develop.

0:51

So we actually have terminology for the different

0:53

kinds of fluid collections that can occur after

0:56

pancreatitis for our interstitial edematous pancreatitis.

1:00

Those fluid collections can wall themselves off

1:02

a bit, and they can be called a pseudocyst after

1:04

four weeks, but they're called acute peripancreatic

1:06

collections for the first four weeks after

1:09

imaging, and then they could turn into pseudocysts.

1:11

If the pseudocyst of edematous pancreatitis is causing

1:15

a patient's symptoms, they may go in with a myriad

1:18

of opportunities to drain those percutaneously,

1:20

drain them endoscopically, drain them surgically.

1:23

So those are all plenty of pseudocysts in

1:25

the world for interventionalists to go after.

1:28

Again, you would only want to drain a pseudocyst

1:30

though if it's complicating, if it has some

1:31

kind of symptomatology for the patient.

1:33

Either they have early satiety from its

1:35

impact on the stomach or something like that.

1:38

Now, in necrotizing pancreatitis,

1:40

we get a mix of fluid and necrotic material.

1:43

I, as a resident, they used to describe this as dog

1:46

meat pancreatitis, which I never really understood what

1:48

they meant by dog meat because I think that I really

1:50

like dogs, and I don't want to think about dog meat.

1:52

And then I finally realized what they

1:54

were talking about was canned dog food.

1:57

If you've ever looked at a can of dog food, it has.

2:01

The most disgusting things in it.

2:02

It's like that gelatinous goo and

2:04

some meat in there or whatever.

2:06

So the idea is that a necrotizing pancreatitis

2:10

is a fluid collection that has like.

2:12

Gel and necrotic bits of pancreas, necrotic

2:16

bits of the fat, you're actually decreasing

2:18

your calcium in your body because the pancreatic

2:20

juices are making soap out of your fat.

2:23

Saponification, that's not a good idea.

2:26

So we describe this as, uh, necrotic.

2:29

Fluid collections.

2:30

They're kind of described as dog meat.

2:31

They're very hard to deal with in the acute

2:34

setting. Over time, after about four weeks, it can

2:37

actually evolve into walled off necrosis, which

2:40

is oftentimes referred to as WON for short.

2:43

But let's look at these.

2:45

Here's the patient who we just

2:46

saw with necrotic pancreas.

2:48

Six days after that initial CT scan we evaluated.

2:51

They've developed ascites.

2:53

They're not doing great.

2:53

They have pleural effusions.

2:55

They're definitely not feeling well.

2:56

And as you come down, you're

2:58

going to see that it's hard.

3:00

The pancreatic tail here in the splenic, um, hilum

3:02

is seen in the pancreatic body, but you have complete

3:04

necrosis of that region of the head that was.

3:07

Minimally enhancing on the prior study,

3:09

so that is acute pancreatic necrosis.

3:12

Here you can see a tiny bit of the uncinate

3:13

process still enhancing in the pancreatic head.

3:16

Again, lots of fluid, so that patient not doing great.

3:20

This is the excretion of contrast into the gallbladder.

3:23

That was from that prior CT scan.

3:24

We refer to that as vicarious excretion of contrast.

3:27

So that's a normal finding in a patient after imaging.

3:30

So we have lost an entire chunk of the pancreas.

3:34

It is now necrotic, and who knows where this

3:36

pancreatic duct is draining into, but probably

3:38

just into this free fluid in the abdomen.

3:41

So let's see this patient again.

3:43

A couple of weeks later.

3:44

This is five weeks after the initial treatment.

3:46

So now we're looking at not that first

3:49

four week interval of necrotic collection.

3:51

Now we're looking at that walled off necrosis, and

3:53

you'll see that this has become much more organized.

3:57

You'll see that the fluid collection

3:58

now has a capsule to it.

4:01

That it's emanating from an complete defect in

4:04

the pancreatic head here, unlike a pseudocyst

4:07

where the pancreas would still be intact, and

4:09

you could see the whole pancreas that walled

4:10

off necrosis is actually encompassing a part

4:13

of the pancreas, which is completely necrotic

4:15

and has been occupied by the fluid collection.

4:19

We even have these big loculated fluid collections coming

4:22

all the way down that anterior pararenal space.

4:25

These imaging situations can be extremely dramatic.

4:29

Again, always treat the patient if they aren't

4:32

as symptomatic from these as you'd expect.

4:34

Treat the patient, not the images.

4:35

A lot of, um, complications can occur as

4:38

a result of unnecessary drainages, so they

4:40

really just try to drain the very needed

4:42

collections that are causing the biggest problem.

4:45

But this is a consternation to many services in

4:48

our hospital because it's, it involves surgery, GI.

4:51

Our interventional radiologists, there's

4:53

enough peripancreatic work for everyone.

4:56

So in this case, we had edematous pancreatitis,

4:59

interstitial pancreatitis, and then we

5:01

had a case of necrotic pancreatitis.

5:03

The necrotic pancreatitis went on

5:05

to develop walled off necrosis.

5:07

That is a dreaded outcome of pancreatitis.