Our first question is I've seen a couple of pancreatitis episodes after use of diabetes drugs. So any, any thoughts on, on why that might be happening? Any comments? Yeah. So we knew that some of glutide and some of the other newer therapies have been associated with acute pancreatitis and there's potentially slightly increased risk in Ozembek. There was a study that showed that Ozembek had increased the risk of pancreatitis. It was 0.3 per 100 person years compared to comparators, which was 0.2. So certainly it is a risk. It's like I had pointed out, it's a risk with a lot of different medications. So if you have a high index of suspicion that it's related to the medication itself, the recommendation is that you stop the medication and then do not resume it in those patients. Thank you. Our next question is what criteria would you look at to determine if a patient needs an admission for pancreatitis versus possibly treating them as an outpatient if it's very mild? Yeah. So I think it really depends on the patient's symptoms and their hemodynamic status. So the first thing is SIRS criteria, if it's very mild, they should not be meeting any of those criteria. And then secondly is, are they able to tolerate oral fluids? The most important thing that we can still do is goal-directed fluid therapy. Hard to really judge that in the first 24 hours, in my opinion. And so a lot of times they'll be in the ED for at least that timeframe. And then when you're looking at their numbers, are they clinically improving? Are they able to tolerate at least oral fluids without a lot of vomiting and can their pain be controlled? John, I don't know if you have anything to add to that one. So I think that it's unusual for patients coming to the emergency department and the throes of acute pancreatitis that you're going to be able to send them home. Does that sound fair to you, Sarah? I think that's still the bottom line. Now if a patient's coming in with acute pancreatitis, they're usually sick. If they have an exacerbation of chronic pancreatitis pain, not acute on chronic pancreatitis, there's a good chance you might be able to send them home by up titrating their analgesia. But I think what we're talking about is acute pancreatitis and really with acute pancreatitis, you want to treat their pain and above all else, keep them hydrated, which is going to be a challenge to do at home because they're going to have a hard time with getting enough fluid down to make up for all the third spacing of fluid out of the vascular and into the interstitial compartment. And we all know that unless you keep the pipes full, the risk of that acute pancreatitis turning into necrosis of the pancreas is going to be exacerbated. And as Sarah would tell you, you know, there are clues in the blood work that are going to tell you if the pipes are not full. For example, if the hemoglobin is inordinately high, that's a bad sign because you're getting hemoconcentrated because your pipes have leaked out fluid. And so the red cells are left in the pipes and the fluid is not there. And so you're hemoconcentrated and you need to replace that. You need to keep replacing that. The patient's not going to be able to do that by mouth if they're having a lot of abdominal pain and nausea. So generally these patients, at least in the United States, end up getting admitted usually to a regular hospital bed where vigorous intravenous hydration with crystalloid is administered along with analgesia and anti-emetics if that's needed. And if they just have an acute interstitial pancreatitis, they're going to turn around within a couple or a few days. And then once they've proven that they can eat, you can send them home. But yeah, I think the bottom line is get the pipes filled up. Keep the pipes full. Don't let interstitial pancreatitis turn into necrotizing pancreatitis. That's really what we want to avoid because those are the patients that develop serious morbidities and risk for mortality. Anything to add to that, Sarah? Yeah, I completely agree. I think there are some patients who will come in and they may be boarding in the ED for a period of time. And depending on the situation with beds, that's probably the only example I can think of where they're going to be going home rather quickly. There are particularly the medication-induced ones that they can turn around in a good 48 hours if it's really mild. But less than that's pretty unusual. I agree. Yeah. It's a great point. I think we also have to take medical legal considerations into mind here because what you don't want to do is blow it off and send a patient home and they get worse and they don't come back in time. And then what could have been a pancreas that you could have kept alive is now dead. And then they either develop infected necrosis and have to be debrided multiple times, or they kill the tail of their pancreas and they become brittle diabetics and suffer downstream complications resulting from that diabetes. And then you've got a pretty sad and chronically ill patient with a lower life expectancy on your hands. And you'll be both medically responsible for that and medical legally responsible for that outcome. Yeah. And so really what you're looking for in these patients is you're actually looking for that hemodilution. Their hematocrit and their hemoglobin should be going down. And if they're not going down, they're not getting enough fluid. Thank you. And we'll move over to Kim for a few questions. And Kim, you defer to your colleagues as you would like. So what would prompt a provider to choose CT enterography versus MR enterography to support or rule out the diagnosis of IVD? That's a great question. And I think, again, I think when we discuss some of the diagnostics and really evaluating CTE versus MRE, and one of the things to definitely consider is radiation exposure, especially with CTE. We have a lot of young patients. We talked about this from the beginning, that bimodal presentation. These are young patients. And I think for myself, I've really shifted my practice in trying to eliminate as much as possible this radiation exposure. So if a patient has underlying kidney issues, of course, I'm not going to choose CTE because you need IV contrast. And of course, we have these younger patient populations. I'll tell you, I've really shifted and used MRE way more frequently than CTE, unfortunately, or I should say, as it turns out, I do work at a community-based hospital. So sometimes MRE, initially, I'll tell you until about two years ago, was not available for me. I didn't have a radiologist that could read it. Now that MRE is more widely available, I definitely attempt to convert and use MRE over CTE. Why else wouldn't I use it? Of course, if a patient has a pacemaker and I can't use an MRI machine because of a different contraindication, if they're exceptionally claustrophobic and I need to get my interventional team available to give sedation, that would be another reason. But I usually veer in the side of doing MRE nowadays, especially in my younger patients. Anybody else want to weigh in on that? Dr. Martin, Sarah, any thoughts? Tim, I want to actually ask you a question about that, you know, and you kind of delved a bit into the issues of availability of MR, you know, which is not only related to what hospital you're at, but how stacked up they are with MRs. The magnets cost a lot more than a CT scanner does. And there are a lot of disease processes that are competing for use of that MR magnet. And so it may or may not be as easy to get as a CT from a promptness standpoint. But the other point that I want to bring up is getting these things reimbursed. Are you having a harder time getting third party payers to approve getting an MR for these indications? Because that can also be maybe not a roadblock, but at least, you know, a speed bump in the road that gets thrown out at you. Yeah, I appreciate that thought on the hurdle, right? And I mean, we all definitely can definitely relate with that in practice. I work for a large multi-specialty organization. And part of that is that we do have our own internal system of getting everything approved. So I'm fortunate in regards to that sense. And if something is not approved, then I'm the person that has to do the overall peer to peer to get it approved. When it comes to, you know, but in a great point, though, Dr. Martin, is that if this is a patient who is acute and in the hospital, I'm not waiting to do an MRE, right? I'm doing a CT, right? I'm going to get something that needs to be done, that needs to be done, if it needs to be done right away. CT, of course, is a lot quicker, prompter, easier to get done versus, of course, an MRE. I think for me, an MRE is something that when I'm looking to help make a diagnosis, right, to kind of work. But in regards to an acute setting, not necessarily my first test. So our next question is, is ESR also a good inflammatory marker for UC? Thanks, Eden. And, you know, yeah, we do use Cedrate. I didn't put it up there because the things that we have to consider about Cedrate is, remember, it's not specific to inflammatory bowel disease. So we don't want to get kind of like muddy the waters a little bit. And that test alone shouldn't guide us in regards to saying that a patient has inflammatory bowel disease, right? A CRP can be elevated for many reasons. And we talk about our patients with inflammatory bowel disease, we recognize many of them have overlapping symptoms, right? That also can create an elevated, you know, Cedrate. So can we use it? The answer is yes. I use CRP much more frequently, I would have to say. And again, mainly because of the fact, remember, it's not as sensitive or isn't actually sensitive to just GI inflammation. To jump back over to Sarah with this question, do patients need, or do patients with pancreatic pseudocysts need surveillance imaging every three to six months indefinitely? Do they have increased risk of pancreatic cancer? Sarah, thoughts? Yeah, that's a great question. So, you know, pancreatic pseudocysts, there are potential for complications for sure. And so in addition to the infection, which we all talk about, in addition to the enlarging of it and potentially causing some obstructive pathology, there can be splenic complications. So splenic vein thrombosis, you can get splenic infarction, you can get a massive hemorrhage from it. You can also get rupture of the pancreatic pseudocyst or hemorrhage from the pseudocyst. Patients can develop shock related to that. And so, you know, when we're looking at them, do they cause cancer? Not necessarily, no, but the pseudocyst itself, the episode of acute pancreatitis can happen because of pancreatic cancer. So in these patients, if you are really evaluating them, you can't find the ideology for them. Sometimes you are looking to say, is there a hidden mass underneath? Is there a malignancy that actually triggered all of this to start? When we're following them, once I see that they're starting to regress in size and they're stable, I don't necessarily follow them indefinitely. You know, once they become a small pseudocyst where I'm not concerned about complications, and then I will typically stop imaging them. Sarah, if I can add to that, you know, one thing that we always want to be aware of in settings of, you know, pancreatic and peripancreatic fluid collections is ascertaining that there isn't some evidence of a pseudoaneurysm forming from an artery there. Because if that bursts, then you're going to have severe hemorrhage that can be life threatening. And if that was seen on an imaging study and you didn't pick up on that, you're going to be in trouble and the patient's going to be in even bigger trouble. And you know, the people die from pseudoaneurysm bleeds. And so, you know, that's one of the reasons that we follow up these fluid collections to a nuanced point at which we're comfortable letting them go. Does that sound reasonable, Sarah? Yep, absolutely. Completely agree. So let's jump back over to Kim for this next question. Are there still any trials for patients to enroll in stem cell therapy for IBD? If so, what are the outcomes? Are patients still on biologic therapy despite stem cell therapy? Would you recommend stem cell therapy for IBD patients? If so, which IBD disease would benefit UC or CD? So I'm going to start by saying, I think this is, you know, I think the best answer for me to say here is that I'm a community-based nurse practitioner and using stem cells specifically for IBD is something that is definitely out of my realm. We're very fortunate that Illinois, we have things such as Northwestern and the University of Chicago. They're very, very close by. I know that there have been some studies, I may defer this to one of my other colleagues because I'll tell you that if a patient is that severe, we're talking about stem cell transplantation. This is not something that we would do in a community-based practice. And I would definitely have, you know, referral to a tertiary care center, which I think as advanced practice providers, there's nothing wrong with that, right? I think that there's something that you definitely need to know when you need to reach out for assistance. And here too, I'm going to reach out to one of my physician colleagues and counterparts if they wish to add in, but also recognizing the importance of having partnership with tertiary care centers that are around you. Dr. Martin, anything to add there? Nothing at all. That's complete. Thank you, Kim. Excellent. Next question. Would there be good criteria or any kind of guidance or tool for determining remission of IBD-encompassing endoscopic evidence, specifically the Mayo score, clinical symptoms, and lab markers? Eden, can you repeat the beginning of the question I posed? Sure. So they were just looking for any kind of criteria, guidelines, or tool for determining remission of IBD. So looking at, of course, specifically if we're looking at tools like for Crohn's disease, we have a Crohn's disease activity index score, a CDAI score. So we're looking at Crohn's disease activity index score, I'm telling you we can use that, which includes symptoms along with, it doesn't include endoscopy, so just that we keep that in mind for this. And of course, the Crohn's disease activity index score of 150 or less is indicative of technical remission. So that's something that we can use from a Crohn's disease perspective, but I'll be honest with you, it's traditionally used a lot more in clinical trial than I would say in practice. I think for Crohn's disease, it's a little bit harder because of the fact we have small bowel involvement. So not always do we have colonic involvement. So that becomes a little different, but again, they do have Crohn's disease activity index score. And as mentioned in the question, a Mayo score, right, of using a Mayo score is also very, very helpful. And again, a Mayo score usually of two or less is indicative of usually remission, right? I will tell you that a great, another tool that one has, I use it all the time. It's an app that I have on my phone, it's MDCalc, M-D and then Calc, C-A-L-C, right? It's a little app that I have, I always say that there's always an app for that, right? And it has, which also has APP in it, by the way, there's always an app for that, right? So, which includes APPs, by the way, so, and that in itself has great tools that has the Mayo score. So you can include stool frequency, bleeding score, so on and so forth, and it helps create your Mayo score, which then actually can tell you, is your patient in remission, you know, where are they at? Do they have mild, you know, mild to moderate disease, or are they still in a severe disease? So those are the ones that I traditionally use as well in my clinical practice. Excellent. Jill, a couple of questions to put your way. What do you recommend for patients who complain that Imodium causes significant daytime drowsiness, even when taking it only at night? It actually comes in a liquid format, so they could look at using the pediatric dose. I mean, that would be my best recommendation. Lamodil is the prescription, which is, has a greater sedating effect. So they could look at getting the liquid one and looking at dosing it with a pediatric dose. That'd be an option. Also bulking up with fiber. Now, fiber does not help with microscopic colitis necessarily, but if it is more of a functional diarrhea, then I recommend starting on Fibrocon tablets. So the tablet formula will help bulk up the stool, so it helps reduce the number of loose stools. Jill, I'm not an expert in this area like you are. So I want to ask you a question about that. I'm not specifically aware of Imodium-related hypersomnolence. I've taken it before and I didn't experience that, or I thought I was just sleepy because I was running to the bathroom so frequently and I was just exhausted from that. But what's the deal with that? Do you know what the mechanism is and is it common? I don't know. I don't hear that comment, to be honest with you, because I see plenty of 70 and 80 year old females that I'm giving them that recommendation, but usually they'll take it at nighttime and then that will keep them at bay for the rest of the rest of the day. How about you, Kimberly? I see you nodding your head. I was going to say the exact same thing. I usually tell my more mature patients, because no one's old, right? We're just more mature. So I actually tell them if I'm going to do a scheduled dosing that they do it in the evening time. I do the exact same thing, Jill. And I've actually found some great benefit with that for our more mature patients. You kids. If nothing else, they come back and they tell you it's like the best sleep aid they've had and they seem happy for both reasons. So there is a product that I want to share with our attendees. It's called the Banatrol, B-A-N-A-T-R-O-L plus. And what it is, it's a prebiotic. It's bimuno prebiotic, and it is for diarrhea and loose stools. So it's actually, it's given for patients who have diarrhea associated with stools that are lactose intolerant or associated with the flu or post-antibiotic treatment, even tube feeding. It's used in the oncology world and or post-treatment for clostridium difficile. So this has been known to help reduce the number of bowel movements as well. And I'll be candid. A patient of mine told me about this about eight months ago. So we're going to sneak in one more question before we go to our afternoon break. A lot of our questions don't get answered. Our faculty will type them in and, you know, a couple people offered some cases and, and we will have time at the end in our round table where we can hit those then. So just quickly, and I'll start with you, Jill, and then anyone else can chime in. Can you talk briefly about diagnosing patients with IBSD versus functional diarrhea? Well, actually functional diarrhea is a catch-all term that is irritable bowel syndrome. So when we, as a clinician, when we talk about functional bowel disorders, we're talking about the spectrum where Kimberly has ruled out that they have ulcerative colitis or Crohn's disease. So now this is a functional state, meaning that it's the mechanism of action is related to that brain gut disorder. So it's a visceral hypersensitivity. So actually functional bowel disorder can be under the spectrum of IBSD, IBSM, mixed or alternating diarrhea, constipation, or IBSD. Wonderful. And we will, shall we go ahead and go to break to keep ourselves on time? I know the faculty want to type some answers. I'm hoping Kim, you can stay around. We have a couple of things here if you're available that I think will fall in your court as well, but otherwise shall we just, we will break and come back at 315 if that sounds okay, Jill, 315 central. That sounds great. Sounds great. Okay. Thanks everybody. All right.

pancreatitis

inflammatory bowel disease

Imodium

diabetes drugs

CT enterography

MR enterography