Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole, and we have three UAB Medicine physicians here in a thought leader panel to highlight pancreatitis. Joining me is Dr. Sushanth Reddy, he's a hepatobilliary and pancreatic surgeon in Surgical Oncology, and he's an Associate Professor at UAB Medicine; Dr. Andrew Gunn, he's an interventional radiologist and an Associate Professor; and Dr. Ali Ahmed, he's an interventional gastroenterologist, and an Assistant Professor.

Doctors, thank you so much for joining us today. Dr. Reddy, I'd like to start with you. Please give us a brief definition of pancreatitis, the prevalence, the scope of the issue that we're talking about here today, and how has our understanding of pancreatitis, the pathophysiology, evolved over the years.

Sushanth Reddy, MD: Well, thank you for that question. So pancreatitis is essentially inflammation of the pancreas, which is a long, stringy organ located in the retroperitoneum, which means the back of the abdominal cavity. Here at UAB, we see roughly 1000 patients a year with pancreatitis, and so we expect that a large percentage of the population will suffer from this at some point in their lives. We've known about pancreatitis for over a hundred years now. The pathophysiology is still being carefully elucidated. But that being said, most cases are related to either gallstones or, in the United States, unfortunately, alcohol use.

Melanie Cole, MS: Wow, that's interesting. And Dr. Reddy then, expand a little on the latest diagnostic trends. We're talking about acute and chronic pancreatitis. Can you separate those out for other providers?

Sushanth Reddy, MD: It's a little tricky to go through it. I think most providers understand what acute pancreatitis is. That's acute inflammation of the pancreas, which is usually associated with a systemic inflammatory response syndrome or SIRS response. For those patients that have chronic pancreatitis, that can either occur because of several episodes of acute pancreatitis stacked on top of each other over the course of a patient's life, or they can occur just simply because of chronic inflammation without acute inflammation going on in the pancreas. Radiographically and pathophysiologically, the two differ dramatically in their presentation, the way we see them on scans and the way we go about treating them.

Melanie Cole, MS: Dr. Ahmed, speak about intervention for acute pancreatitis versus taking a more conservative management approach. Speak just a little bit about what happens.

Ali Ahmed, MD: Sure. When people present with pancreatitis, they have severe pain. And for us to diagnose it, it's usually looking at certain markers, lab values such as lipase, which can be elevated. We can look at pain. Typically, people have pain middle of their belly, and it can radiate out to their back. As Dr. Reddy mentioned earlier, the pancreas is a retroperitoneal organ located in the back of the abdominal cavity. So often, patients describe a tight pain that radiates around their abdomen to the back. And radiographically, we'll see imaging changes of inflammation. And to make the diagnosis of a acute pancreatitis, you'll need two out of those three typically. But you don't always have to jump to imaging right away.

So once you've diagnosed pancreatitis from this perspective, you'll start by conservative management, often by not feeding the patient, giving them fluids and IV pain management as needed. And most patients are managed with this sort of regimen. About 20% of these people may go on to develop a fluid collection, that can be known as a pseudocyst. And about 80% of those pseudocysts will get reabsorbed by the body and managed again with this conservative management. But about 1% of patients, those fluid collections can become infected. In which case, we'll have to talk about draining them, either endoscopic, which would be through the stomach, we'll make a communication between the stomach and the fluid collection and if there's infection, do intervention through that new access point or percutaneous by our colleagues in surgery, Dr. Reddy or an interventional radiologist such as Dr. Gunn.

Melanie Cole, MS: And Dr. Gunn, you're up next. So tell us a little bit more and expand on what Dr. Ahmed was just saying as far as the role of endoscopic ultrasound-guided drainage. How how has imaging changed in your career for pancreatic issues like this?

AJ Gunn, MD: Yeah. I don't know that imaging has changed much, but one of the things that I find really satisfying about working at UAB is this close collaboration that we have with our colleagues in Gastroenterology, our colleagues in Surgery. And so, maybe three or four years back, we all kind of got together and recognized the need for a more collaborative, unified approach for patients with pancreaticobiliary cancers and pancreatitis as well. And so, we formed this Pancreaticobiliary Disease Center. And so, it's got surgeons inside of it. It's got endoscopists like Dr. Ahmed inside of it. It's got interventional radiologists, diagnostic radiologists, pathologists, genetics. And so, each week we get together, we talk about new cases, followup cases, patients that might be inside of the hospital.

And so as part of this, I was in one of the working groups that worked on what is our pancreatitis protocol going to look like? And so, I think one of the advantages inside of a place where there's multidisciplinary collaboration like this is that we're able to come together, look at each other's data, understand each other's perspectives, and come up with a very unified protocol for what it looks like when a patient with pancreatitis comes into UAB.

And at this point, when someone comes into UAB and has acute pancreatitis that gets referred to Interventional Radiology for drainage, and I look and I see that Dr. Reddy or one of his partners has not seen that patient, it's pretty easy for me to get ahold of them and say, "This is something that you guys need to see this patient to provide some sort of unified response for this patient's inside of the hospital." And so, I think where we have changed-- back to your original question-- where we've changed in our process over the last three to five years is a more unified approach to what drainage looks like, kind of an endoscopic-first approach, because that allows internal drainage and patients don't get as dehydrated. But then, learning about the advantage of dual drainage when the endoscopic drainage doesn't work, and then we come in with percutaneous drainage afterwards. Keeping that drain retroperitoneal. What is the size of that drain? How often do we see that patient in followup? And then, that unified approach, I think, helps to provide a more defined pathway, decreases kind of the length that these drains are in, decreases their length of hospital because we're all following it together rather than kind of this fragmented approach that we maybe had five to seven years ago. So to me, that's the biggest thing that's changed, is our more unified, structured approach to patients with pancreatitis, more so than the imaging itself.

Melanie Cole, MS: That's so interesting, which leads me well into my next question for Dr. Reddy. When we think of surgical versus endoscopic versus percutaneous approaches, as Dr. Gunn was just discussing, how do you decide between surgical drainage, endoscopic necrosectomy, percutaneous drainage in these severe cases, tell us how you make the decisions and what key considerations in determining when to proceed with surgery in the first place.

Sushanth Reddy, MD: So, surgical drainage used to be the mainstay for managing these patients. And to this day, I get phone calls from providers all over that ask me a surgeon has to see this patient because they need an urgent surgical drainage. They're shocked to hear the fact that I probably do one or two surgical drainage procedures a year right now. That just shows, as Dr. Gunn was pointing out, the evolution and the way we go about treating these people.

Our preferred way to drain these folks is endoscopically whenever possible. Again, for all the reasons that we've laid out, you don't end up with drains hanging out your body. You don't get dehydrated. Our first question, however, is is the fluid infected? The fluid's infected, it has to be drained, whether it's endoscopically or percutaneously. The way we go about determining that is then to see, is the collection mature enough for endoscopic drainage? And what I mean by that is that it's got to have a thick wall so that Dr. Ahmed can easily get ahold of it, endoscopically, and drain it successfully. If it doesn't have a thick wall, then we have to go to percutaneous drainage. Now, there are times where the collection may not be in close proximity or vicinity of the stomach. If that happens, there's no way Dr. Ahmed's going to be able to drain it endoscopically. And so then, we only can do it percutaneously.

We're increasingly finding ourselves having to do what's called dual drainage, where we will have Dr. Ahmed and Dr. Gunn drain these patients out. And then, in rare sub-select patients where the necrosis and the material is so thick that it just cannot come out through either of those approaches, we have to start talking about surgical drainage. But even to do that, usually requires failure of endoscopic or percutaneous drainage First.

AJ Gunn, MD: You touched on something that is really interesting and I think is a huge strength of our center, is the availability of other services, just outside of surgery. I mean, do you have a sense of outside of an institution like UAB, how often other surgeons are still doing surgical drainage for pancreatitis? And Dr. Ahmed, kind of same thing. I mean, how available is endoscopic drainage out in the community?

Sushanth Reddy, MD: Well, to start with that, there are providers who still perform surgical drainage, largely because they don't have access to all of you to help out. And so, the end result is we still see patients who get surgical drainage procedures in small communities.

In order to do that, number one, you have to have the expertise and the knowledge of the anatomy around the pancreas. And the main reason why we stopped doing a lot of surgical drainage procedures is because a lot of these folks ended up with a lot of bleeding complications more than anything else. Increasingly though, because of our good marketing and our good communication with the local physicians, they've stopped doing those, in this region at least, and they're getting on the phone and letting us know that the patient needs to come to UAB or to another tertiary care center where we have all the availabilities.

Ali Ahmed, MD: I was going to add more and more people are advanced trained and are capable of putting in the lumen-opposing metal stent that provides the endoscopic access and drainage of the pseudocyst or walled-off necrosis. But the key is for the center to have a team approach such as we have here at UAB with a hepatopancreatic biliary surgeon, an interventional radiologist with expertise in pseudocyst and work in the pancreas, as well as sometimes we'll put these drains in and they can cause bleeding. And many times, our interventional radiologists have come in later to take care of the bleeding, and rare case it's the surgeon. So, that's where the team approach that we employ here that you touched upon earlier about evaluating pre-treatment, what our plan is, and then following those patients with periodic imaging scans to see if they're getting improvement and determining whether they need multi-gated drainage. Do we have to upsize the drain? Do we have to go back and re-intervene and see if the patient is clinically getting better?

AJ Gunn, MD: Yeah, it's always from an interventional radiology perspective. It's always very eye-opening when you speak with other physicians who say, "You guys can do that? Oh, that's possible?" And that happens both inside UAB and outside UAB. And so, it's really what we sometimes consider as commonplace isn't so commonplace. That's why I think educational opportunities like this are really, really important.

Sushanth Reddy, MD: Oftentimes you hear the phrase when you're a hammer, everything around you is a nail, and what you can do is not necessarily what you should do. And that's something that we strongly encourage people to remember out in the community when they see these very complicated patients.

AJ Gunn, MD: Well, something I also remind our trainees and faculty here, I bring up the pancreatitis protocol and the Pancreaticobiliary Disease Center a lot because even inside your own specialty, you think, "Oh, this is what we should do because we can do it." But when you look at other people's data and you understand this might be better for this specific patient. And when you kind of really do it with this collaborative approach, I really do think it's more patient-centric rather than just disease-centric. And so, I've really found that to be a beneficial aspect of how we approached it over the last few years.

Ali Ahmed, MD: Just to circle back a little bit, some of the other changes that have happened in pancreatitis is just the medical management as well. A recent paper in the England Journal of Medicine, by Dr. de-Madaria and his group talked about high intense and moderate intense fluid in management of pancreatitis. And that study has shown that sort of a more moderate approach was better. So, we've employed that change too here, as well as employing nutrition strategies. And Dr. Ready and Gunn will always let me know, "Hey, we've got to feed this patient empirically. What do we have to do so that they can get nutrition to assist them in getting better and recover from their pancreatitis?"

Melanie Cole, MS: That was so well said by all of you. And Dr. Ahmed, as we think of recurrent chronic pancreatitis quality of life considerations for patients, what's involved in that? Tell us a little bit about followup visits, care close to home clinics, because people have to travel and that can become quite limiting. So, speak about the quality of life and how you all work together to help that patient.

Ali Ahmed, MD: Yeah, chronic pancreatitis becomes sort of a lifelong challenge for patients. Nutrition is part of it. Access to a physician with expertise on the pancreas to liaise with their primary care physician to help them feel comfortable with managing their disease process, treatments such as pancreatic enzyme supplementation to make sure those medicines are dosed appropriately.

Pain control. So, pain can be a big problem. There are endoscopic and IR-guided treatment for pain as well as pharmaceutical. So endoscopically, it's the EUS-guided celiac plexus block where the area known as a celiac plexus, which takes pain signals from the middle of the abdomen and sends it to the brain, is injected with pain medicine and a steroid to dull those signals going to the brain. And the idea here is to cut the responsive pain in half. So if someone feels their pain is eight out of 10, with 10 being the max, to maybe a four out of 10, where they're able to carry out with some of their daily activities.

Sushanth Reddy, MD: I would add that that's the hardest part of people with pancreatitis moving forward. It's really hard with people with chronic pancreatitis to get them back to a zero out of 10 or a 100% of their normal activity. Expectations are critically important so that we can make people understand that what our goals are may not coincide with what they are hoping to get.

AJ Gunn, MD: We've seen a huge growth along those lines. We've seen a huge growth of image-guided pain procedures here at UAB. And I think as our surgeons and our referring physicians learn what we can do different-- and it's not just with pancreatitis, but different kind of, you know, postoperative pain, post pancreatitis pain-- we've seen a huge growth. And so, I think anybody kind of listening to this who has somebody kind of with chronic pain would be worth referring and having a conversation around that because, as Dr. Ahmed was saying, with EUS-guided celiac plexus block, when we started working through this protocol, I thought, "Gosh, all of these should be percutaneous celiac plexus blocks." But when you look at their data, they do a really good job, they're already there doing biopsies for the most part anyway. And so, that was a really great place for us to collaborate. But certainly, all sorts of chronic pain and patients with chronic pancreatitis, people want to avoid opioids as much as possible, and that's a very worthy goal over time.

Melanie Cole, MS (Host): I'd like to give you each a chance for a final thought here. And Dr. Gunn, as long as you were just speaking, what would you like the key takeaways to be for other providers about the importance of this multidisciplinary collaboration for patients with pancreatitis, and what you feel are the most important bits that you want them to take away from this episode today?

AJ Gunn, MD: Well, thanks for the opportunity. And I would just go back to kind of my original comment, is that we have a protocolized, unified, multidisciplinary approach to pancreatitis that I think reduces some of the fragmentation of care that you might see somewhere else. As Dr. Reddy was saying, if you're a surgeon treating this and you don't have access to all of these different resources, then there's only one way that you know how to treat it. And so if you're listening to this and you think that there is value in some of this multidisciplinary approach that you don't necessarily have access to, this is where we can be helpful. That's the thing that I would emphasize out of this episode.

Melanie Cole, MS: Dr. Ahmed, are there any promising new therapies, clinical trials, and pancreatitis treatment that you find particularly exciting? Anything you'd like to mention?

Ali Ahmed, MD: Absolutely. And just to answer for that last question, you know, pancreatitis is a complex disease and requires a team approach. And I think that's exactly what Dr. Gunn and Dr. Reddy alluded to, benefits that our health system can provide.

As far as new things, people are always trying to figure out what is the cause of pancreatitis? We don't fully understand it. There are some clinical trials here at UAB to look at medications that are anti-fibrosis or anti-inflammatory, and can they have an approach on improving patients with pancreatitis? There are newer techniques and new devices that are being developed to take surgical devices, repurpose them through either the percutaneous approach or endoscopic approach to try to make the debridement more efficient, faster so that patients can heal and recover faster. And then, thirdly, I think we're just becoming better from a surgical and medical management and how we are evaluating these patients when they're in the hospital. So, the hope is long-term we'll be able to find ways to better diagnose or predict which patients can get pancreatitis and then hopefully heal them faster.

Melanie Cole, MS: Thank you for that. And Dr. Reddy, last word to you, as we think of the most critical unanswered questions in pancreatitis management, and as Dr. Ahmed was just discussing things that are coming down the pike, what would you like to see happen in the world of pancreatitis in further research and the key takeaways from this amazing episode where you're all really working together?

Sushanth Reddy, MD: First of all, I would like to say it's been one of the great honors of my life to work with this group here to take care of these complex patients. The team approach we've repeated a few times, that's what works well for these patients, as it does for many disease processes. But especially processes like these where oftentimes patients get a stigma of being, "Well, they must be an alcoholic." And I tell patients, "You don't have to be alcoholic to get pancreatitis. You just have to use alcohol. If you're not careful, it can happen to all of us."

The take home message, I would say, is remember that these teams exist. Don't feel like you have to take care of your patient in a vacuum wherever you are. and you may feel that way, and you may feel like you have to try to do something that is the only thing you know how to do, it's okay to call for help and to talk to other people who can work that through with you. There are many patients whom we don't see here who end up staying in their local hometowns, but they just get on the phone, their providers do, and talk to us. And we work through what needs to happen with those patients to help bridge them from the acute situation they're in to hopefully a more chronic and less life-threatening spot that they could potentially get into.

Melanie Cole, MS: What a great discussion this was today. So enlightening and informative. Thank you all for joining us today and sharing your combined expertise for other providers today. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole. Thanks so much for joining us today.