 Today I want to talk to you about biliary pancreatitis. Now, it is not the most common pancreatitis that we see and depending on where you practice is not going to be the most common type that you see. For us, that will be alcoholic pancreatitis. But today I want to discuss a biliary pancreatitis. Remember, we discussed in a previous video, I'll link to that, we discussed the complications of gallstones. So, gallstones are going to come via the cystic duct down the common bile duct and it's going to get stuck in the ampillar farta. Now how that precisely leads to pancreatitis, we are not 100% sure it might have something to do with the bile that refluxes down the pancreatic duct, releasing all sorts of, at least eliciting some form of response. Whatever the case might be, you end up with pancreatitis. Now again for us, probably will be the same for you, we do see this in older population set and we do see this preponderance of female patients with biliary pancreatitis. And what they present with and what you have to look out for of course is pain, they're going to have nausea and they're going to have vomiting, loss of appetite, severe upper abdominal pain. Now some of them are going to have a history of biliary colic, some of them might even be diagnosed with cololithiasis before, they've had an ultrasound before but that's not always the case. So how do we make the diagnosis? Well when you examine them, you are going to find the tachycardia, you might even find a bit of a temperature and if it's very severe and with alkali pancreatitis we might discuss that when it's very severe, they might have signs of septic shock, they might have pleural effusions, all sorts of severe complications and we'll discuss that at another time. So when you examine them, examine them very tend to upper abdomen, sometimes the whole abdomen and it's sometimes so bad you might think that this patient is peritonitic, that they have a hollow viscous perforation and you want to take them to theatre but you're doing erect chest x-ray, there's no free air. What you want to do really is to get a live phase level, if at all possible a live phase you could also do an amylase, the problem is those levels go down, the kidneys get rid of it and down the line you might get normal results but at least initially you are going to get high live phase levels or amylase levels, go for the live phase, see that your laboratory can do that. That typically for us would confirm the diagnosis and acute mild pancreatitis we are not going to run for CT scan or for anything like that. We reserve a CT scan for the patients who don't get any better or for the patients in whom we really have a diagnostic dilemma then you can send your patient for imaging as far as the pancreatitis is concerned, otherwise we don't do a CT scan. Now what do we do for these patients? We know that there is no treatment for proper treatment for acute pancreatitis, you're just going to support the patient. So we will give the patient a good analgesia, this is very painful and we will use morphine if that is required. Initially if the patient really doesn't feel like it we will let the patient be in the upper mouth and we really guide, let the patient guides us, that's the best way to go about it. Let the patient will guide you as to what they can and cannot eat just to keep a patient not pass blanket leave for an x period of time because that is some protocol that doesn't really work and we don't do that. The patient will tell you when they are ready to eat and also eating without causing pain that really is a sign that the pancreatitis is probably settling down very well. So we let them judge that. Of course we have to check the fluid intake and we have to check the electrolytes so get your laboratory test done, manage the patient's rehydration according to the electrolytes and you can even check their urine output if it's a mild case you definitely have to have if it's a severe case and then you manage according to that and keep up with those electrolytes, keep up with the fluids the patient can take orally but you can also add intravenous, we do not give antibiotics at all and we will reserve that for the acute severe cases that complicate and we'll do tests before we confirm the need for the use of that. So mild cases that you're going to see and manage not to be concerned about antibiotics at all. At times we will give the patient a bit of PPIs, you know we can look at the evidence for that you can look that up, there might be slight improvement sometimes for us we do see depending who's on call really that they do improve a bit. But that's as far as the supportive management go, we don't go any further than that as far as these uncomplicated cases are concerned. So what are we going to see? The majority of our patients are really just going to improve over the next 48 hours. That stone usually goes through. By the way if you do the imaging, don't forget about that, you probably will see cololithiasis, sometimes we only see a bit of sludge, sometimes we see nothing and perhaps was a single small stone that had gone through. We don't really want to see extrapatic bile duct dilatation, if that happens we're talking more cololithiasis and the patient will be jaundiced, we're not talking about that at the moment. You might see a bit of edema in the ultrasound if you're very happy around the pancreas but usually there's gas overlying because the bowel over it is quite distended, the duodenum slightly distended, lots of air in there is what I'm trying to say and air is the enemy of an ultrasound. So the 48 hours patients will usually feel better and we will do a laparoscopic colosostectomy within that admission. We won't let the patient go home, we will do a laparoscopic colosostectomy once the patient really is better. If the patient does not improve, they actually get worse, that probably means that there is a stone stuck in there and we are going to go for imaging and we are probably going to go for an ERCP. So if your patient is not getting better and you've confirmed that with your life pace or doing all the right things, get them to a facility where they can be managed properly and for us it will usually be an ERCP that stone is stuck. If they have gallstone pancreatitis and they jaundiced for us that will also be really be an ERCP. Usually though the stone is going to go through, the patients improve and they get better. As I said we'll discuss this in another video if you get to acute severe pancreatitis that's a whole different ballgame. If your patient does not improve, don't sit on that patient, get them to a facility that can take care of them properly and that's really in the best interest of your patient. So that in short is acute biliary pancreatitis.