Maisam Abu-El-Haija

201 statements · 4 topics · summaries given as host listed separately

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don't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier.

quote · Acute Pancreatitis

The ultrasound is really, that's the most helpful use of it. It's not really to document that the patient has pancreatitis or looking for complications. It's really looking if there's a biliary component.

quote · Acute Pancreatitis

lipase half-life is about 7 days, but it's also more specific because it's mostly elevated if there's intestinal or pancreatic things. MLAse could be due to appendicitis.

quote · Acute Recurrent Pancreatitis

when we aggressively resuscitate, there are some evidence that shows that you could actually flood the lungs and result in pulmonary edema

quote · Hirschsprung disease

So it's not that the sensitivity is different early on, but amylase rises and normalizes much quicker than the lipase.

quote · Hirschsprung disease

The INSPPIRE consortium defines acute recurrent pancreatitis in children as at least two distinct episodes with complete resolution of pain and a one-month pain-free interval, or normalization of enzymes with complete pain resolution in less than one month.

guideline · Pancreatitis

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Maisam's statements about Acute Pancreatitis 67 statements

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Acute Pancreatitis

Quotation Does he meet criteria for acute pancreatitis and based on what I showed you, We think he does Open

Statement Ultrasound is limited in the setting of suspected complications of pancreatitis; CT is the image of choice for complicated cases to better visualize necrosis, fluid collections, hemorrhage, or masses. Open

Statement Amylase rises and normalizes much quicker than lipase, so in a patient presenting 2 days after symptom onset, amylase may not be the best indicator of pancreatitis. Open

Quotation So it's not that the sensitivity is different early on, but amylase rises and normalizes much quicker than the lipase. Open

Statement Lipase half-life is about 7 days and is more specific for pancreatic pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary disease. Open

Statement The most helpful use of ultrasound in acute pancreatitis is looking for a biliary component—CBD dilation suggesting need for early ERCP, or gallstones that change management—not documenting pancreatitis or looking for complications. Open

Statement MRCP is not the most helpful imaging modality during an acute pancreatitis attack because edema obscures ductal anatomy; it is better reserved for workup of biliary and pancreatic ductal issues after resolution. Open

Statement There is no data identifying a superior pain medication for acute pancreatitis; even adult studies have not identified optimal management. Open

Quotation don't be shy of using opioids. Actually, if you use them in in the right patient and right setting, even in acute pancreatitis, you could actually advance feeds and improve the outcomes and send them home earlier. Open

Statement Opioids should not be avoided in acute pancreatitis; when used appropriately, they can help advance feeds, improve outcomes, and facilitate earlier discharge. Open

Quotation The data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate. Open

Statement Early nutrition (within 24 to 72 hours) in acute pancreatitis is associated with more favorable outcomes: it maintains gut barrier function, inhibits bacterial translocation, and lowers the incidence of systemic inflammatory response. Open

Statement A 2012 meta-analysis comparing TPN versus enteral nutrition in predicted severe acute pancreatitis showed enteral nutrition was associated with decreased organ failure, reduced surgical intervention rate, lower mortality, and fewer infections. Open

Statement Studies comparing NG feeds versus NJ feeds in acute pancreatitis show no difference in outcomes; duration of hospital stay and mortality were very similar, even in severe acute pancreatitis. Open

Statement The Ekerwal 2007 study randomized 60 adult patients to eat on admission versus NPO and found that early feeding did not increase abdominal pain and decreased length of stay by 2 days. Open

Quotation Guess what they found? They found that you could feed without increased abdominal pain, so you're going to wait on feeding your patients until their pain is gone, but their pain is going to be the same whether you feed them or not Open

Statement In a Cincinnati Children's study of 38 admissions for mild pancreatitis, early nutrition was safe and feasible, and patients who received feeds had similar pain scores to those kept NPO. Open

Quotation I haven't found a good evidence for the low fat. However, we know that fat stimulates lipase and we don't want to increase lipase. Open

Statement Pilot analysis showed patients with the lowest pain scores were those who ate the most fat; fat intake did not increase length of stay. Open

Quotation The lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat. Open

Quotation It's, it's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home. Open

Statement Aggressive IV fluid resuscitation (more than one-third of 72-hour fluid volume given in the first day) is associated with reduced mortality and reduced incidence of SIRS and organ failure at 72 hours. Open

Quotation really you've got a window and it's a 24 hours and if you don't interject then probably you lost your window Open

Statement In studies of aggressive resuscitation, the late resuscitation group received more total fluid than the early resuscitation group, suggesting a critical 24-hour window for intervention. Open

Statement A 2011 study of 40 patients using goal-directed management (resuscitating to urine output of 3 mL/kg/hour) showed early resuscitation with lactated Ringer's reduced inflammation markers (CRP) compared to normal saline. Open

Quotation And here brings the question of should we all use LR? Again, this is one study. Open

Quotation when we aggressively resuscitate, there are some evidence that shows that you could actually flood the lungs and result in pulmonary edema Open

Statement In a Cincinnati Children's study of 201 patients, those kept NPO with low IV fluids had 35% rate of developing severe pancreatitis, versus 4.2% in those who ate early and received aggressive resuscitation. Open

Quotation The classic story, since we're talking about diseased pancreas, it can't be that easy, right? Open

Quotation when the patients are not NPO enough time and I don't know, Andrew, if you want to comment why sometimes we get the non-specific findings or not adequate to comment Open

Statement Ranson's criteria have not proven sensitive and specific for predicting severity in pediatric pancreatitis when validated in further studies, despite initial promise in a 2002 Midwest study. Open

Statement A Cincinnati Children's prognostic tool using white blood cell count, albumin value, and lipase on admission can predict severity in almost 70% of pediatric pancreatitis patients. Open

Statement Antibiotics should not be used routinely in mild acute pancreatitis or in severe pancreatitis unless there is infected necrosis. Open

Statement When antibiotics are indicated for infected pancreatic necrosis, imipenem or 3rd generation cephalosporins are good initial choices. Open

Statement The INSPPIRE consortium defines acute recurrent pancreatitis in children as at least two distinct episodes with complete resolution of pain and a one-month pain-free interval, or normalization of enzymes with complete pain resolution in less than one month. Open

Statement Workup for acute recurrent pancreatitis includes inflammatory causes (IBD, celiac), systemic illnesses, mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing for PRSS1, SPINK1, CFTR, and CTRC. Open

Statement In a prospective acute pancreatitis registry at Cincinnati Children's (nearly 3 years old), increased weight percentile-for-age (not BMI) during the first attack predicts recurrence. Open

Statement Higher BMI may predict severe pancreatitis course in adults and children based on studies outside the US, though this has not yet been proven in the Cincinnati US population (sample size 85 patients). Open

Acute Pancreatitis

Statement Amylase rises and normalizes much quicker than lipase; in a patient presenting 2 days after symptom onset, amylase may not be the best indicator. Open

Quotation lipase half-life is about 7 days, but it's also more specific because it's mostly elevated if there's intestinal or pancreatic things. MLAse could be due to appendicitis. Open

Statement Lipase half-life is about 7 days and is more specific for pancreatic/intestinal pathology than amylase, which can be elevated in appendicitis, gynecologic conditions, or salivary issues. Open

Statement The most helpful use of ultrasound in acute pancreatitis is looking for a biliary component (CBD dilation suggesting early ERCP need, or gallstones changing management), not documenting pancreatitis or looking for complications. Open

Quotation The ultrasound is really, that's the most helpful use of it. It's not really to document that the patient has pancreatitis or looking for complications. It's really looking if there's a biliary component. Open

Statement CT is the imaging test of choice when complicated pancreatitis is suspected; it best visualizes necrosis, fluid collections, hemorrhage, and masses. Open

Statement MRCP is useful for workup of biliary and pancreatic ductal issues but is not the first imaging modality in acute pancreatitis; edema during acute attack obscures ductal anatomy. Open

Statement There is no data on optimal pain medication in acute pancreatitis; even adult studies have not identified a superior medication. Open

Statement Opioids used in the right patient and setting in acute pancreatitis can allow earlier feeding, improve outcomes, and enable earlier discharge; providers should not be shy about using them. Open

Quotation The data is very convincing that. You need to start it early, and early means really within 24 to 72 hours, and it's been proven. There is no debate. Open

Statement Early enteral nutrition (within 24–72 hours) in acute pancreatitis is associated with more favorable outcomes: maintains gut barrier function, inhibits bacterial translocation, lowers incidence of systemic inflammatory response, and avoids severe complications. Open

Statement Cincinnati Children's replicated the early feeding approach in 38 pediatric admissions with mild pancreatitis (published late 2015); early nutrition was safe, feasible, and not associated with worse pain outcomes. Open

Quotation The patients who received feeds and the patients who were NPO had similar pain scores. These are patients who were evaluated multiple times per day, almost every 4 hours, subjectively and objectively by pain scores Open

Statement Pilot analysis showed patients who ate the most fat had the lowest pain scores; fat intake did not increase length of stay. Patients likely self-regulate and eat more when ready. Open

Quotation The lowest pain scores, this is pain score on the X axis, were actually the ones who ate the most fat. Open

Quotation It's probably that they're ready to eat more. They self-regulate again, so they eat more and they order a burger by their 2nd or 3rd day, and then you feel, OK, you're ready to go home. Open

Statement In the late resuscitation group, patients received more total fluid than the early resuscitation group, but outcomes were worse, indicating a critical 24-hour window for intervention. Open

Quotation you've got a window and it's a 24 hours and if you don't interject then probably you lost your window Open

Quotation the evidence shows that the outcomes are better with aggressive resuscitation. Open

Statement Cincinnati Children's study of 201 patients showed 35% of NPO + low IV fluids group developed severe pancreatitis vs. 4.2% in early PO + aggressive resuscitation group. Open

Statement Ranson's criteria applied to pediatric pancreatitis (studied since 2002, including Midwest/University of Cincinnati studies) initially showed promise but did not prove sufficiently sensitive and specific upon validation. Open

Statement Cincinnati Children's study proposes using white blood cell count, albumin, and lipase on admission to predict severity in ~70% of pediatric pancreatitis patients; this tool still needs optimization. Open

Statement Antibiotics should not be used in mild pancreatitis or in severe pancreatitis unless infected necrosis is suspected (e.g., fever present). Open

Statement When antibiotics are indicated in pancreatitis, imipenem or 3rd-generation cephalosporins are good initial choices based on available evidence. Open

Statement ARP workup includes inflammatory causes (IBD, celiac), systemic/mitochondrial diseases, cystic fibrosis, metabolic conditions (triglycerides, calcium, kidney disease), anatomic evaluation (MRCP, possibly ERCP), and genetic testing (PRSS1, SPINK1, CFTR, CTRC). Open

Statement Cincinnati Children's prospective acute pancreatitis registry (3 years, 85 patients) found increased weight percentile for age (not BMI) during first attack predicts recurrence; abstract submitted to World Congress. Open

Statement Higher BMI predicts severe pancreatitis course in adults and some pediatric studies outside the US, but did not predict severity in Cincinnati's 85-patient sample, possibly due to wide BMI variation in both recurrence and non-recurrence groups. Open

Maisam's statements about Acute Recurrent Pancreatitis 29 statements

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