David Vitale

I think your point there, uh, never use a balloon that's larger than the dilated comet bile duct, which is really important, uh, cause we know that there is some USP literature out there with people looking at, uh, doing dilations of the ampula without doing a sphincterotomy, and there's definitely a higher rate of pancreatitis in those patients.

When things are improving, we don't need to see biochemical normalization. But when the symptoms are improving, we go right to cholecystectomy with intraoperative cholangiogram and coordinate with you just in case there might be a need for an ERCP.

We know that there are metabolic risk factors, uh, hemolysis such as sickle cell, congenital and biliary anomalies like colloidal cysts.

Studies show that if you wait one day when a patient comes in with acute biliary pancreatitis and the amylase/lipase go up, then you do ERCP because the stone is impacted; but most of the time the levels will go right down as the stone passes spontaneously, and you can proceed to cholecystectomy.

Pancreatic fluid collections are defined by time course: acute fluid collections or acute necrotic collections occur in less than 4 weeks, while pseudocysts or walled-off necrosis that may require intervention occur after greater than 4 weeks and have an encapsulated wall.

At Cincinnati Children's, endoscopic pancreatic function testing involves IV bolus of secretin or CCK at time zero, then collecting 3 duodenal aspirates at 5-minute intervals, with point-of-care pH testing to ensure no gastric contamination.