days. And so basically, I spent this morning editing it. So if it's kind of choppy or anything, excuse that. So it's a 39-year-old alcoholic, pancreatitis. That happened actually five weeks prior. He was in the hospital for two weeks, discharged. And then he's now coming in with 10 days of worsening abdominal pain, fevers, chills, temperature to 104.3. So you're worried that something has gotten infected. Leukocytosis to 12.9, lipase is less than 4. So he doesn't have a recurrent pancreatitis. He didn't go home and just drink a gallon of wine and then come back. And of course, the CT was done. And so here's the CT. And you can see this collection here. You saw the collection. And you can see it's continuing there. All of that there, that's all nasty. There's a lot of air in there. So that thing needed to be drained. The thing is, it's not really well-formed on this side. It didn't seem to be well-formed on this side. So we waited on it for about a week. But he was really not improving, failed to tolerate PO. So what do we do at this point in time? What would you guys do? So are you concerned about a spontaneous fistula? I mean, with the amount of air there is? I am concerned about that. Actually, some of the colon was close by to have this extensive collection. And that starts becoming a major problem. Then he had to get surgery. I was worried also that my surgeon's going to go in and try to open this up and have a big open laparotomy. IR could potentially do it. But an IR drain, these tiny drains, they barely really do anything. So I said, all right, let me just at least try to do an EOS. It was a Friday. And I knew the weekend was coming up. Let's kind of see what's going on. Here's the problem. There's air in there. EOS doesn't go well with air. And so as I looked everywhere, I mean, there's not lung here, but it looks like a lung. There's just a ton of air in that area. And I was like, OK, well, there must be something. This collection's huge. That's got to be the only thing in that area. So I went ahead and injected. You'll see a needle come in at some point soon. This is the whole collection. I mean, it's just continuous in collection. All you can see, tons of air. You just can't see that proper collection, that beautiful, big thing that you see normally. But I knew it was there. And I knew this patient needed this. So I went ahead and I'm just going to kind of advance this a little bit. There you go. There's a nice collection. There's a nice part of the collection. Would you guys want me to drain that? Yes? Who's going to drain? Is that spleen at the bottom? No, that's the gallbladder. We're not going to be draining the gallbladder. So if you look back. Oh, that's the sludge at the gallbladder? Yeah, that's the sludge and stones in the gallbladder. So maybe he had, we're being a little bit unfair to him, he didn't have alcoholic pancreatitis, although, I don't know. Yeah, you can see the stones were right there. Those are the nice, beautiful stones. And that's the gallbladder. So yes, it was like, oh my god, I got a collection. Then I was like, no, I'm not draining that. So let's continue. Would changing the patient's position help you to get fluid closer to the US? There isn't enough fluid there, period. Even you can see there's not a lot of fluid. So there's my needle. And I said, even if you do that, if I put this needle in there and I can inject in there, potentially I can get fluid in there, and I could be able to see it. And I injected. And actually, this picture is not fair. Some of the pictures I took were a little bit better. I could actually get a nice collection. And I was able to get a nice collection. I was able to see that it was formed, that it wasn't extravasating out into the middle of nowhere. So that kind of made me a little bit more reassured. I still can't see a really nice collection. I just really don't see it. And if you're not comfortable with this, I'd probably say forget it. Leave this. But I knew this collection was big. So I went ahead and deployed the Axios anyway. And that's the Axios. That was it going in. I'm going ahead and doing the distal flange right into that area. Should be there. Yeah. There it is. And then it's coming back. I was very nervous when I was trying to do this during the endoscopy. It's Friday, and it's close to 6 o'clock also. It was. And then I deployed the inner flange. And it's like popping a zit. Oh, it was so satisfying. So satisfying. I was so happy to see that rather than colon stuff coming out, stool coming out. So it worked. It was good. There were a lot of reasons to be uncomfortable with this procedure. But I think you have to inject, and you kind of do it. This is all pus. And so this was doing what it needs to be. So the points to consider. Air sucks, at least for EUS. Use fluoro in complicated cases. A lot of people get away with necrosectomy without using fluoro. Fine, do it if you really are comfortable, if it's a really easy shot. But use fluoro if it's complicated. For us, we don't have these fluoro tables. We actually have to bring a C-arm, so it's a little bit more complicated. And then inject contrast. And not only just to get an assessment of the size, to ensure it's encapsulated, to look for tracks in deeper areas, also just to fill it up more and be able to get you a nice target. And the concern was that you might be going into a viscous, like colon or something. Yeah, or I could just be going into peritoneum or something. After you punch it with a needle, maybe loop a guide wire and see what shape the guide wire takes. That would give some idea. That would have been a good idea. But if I had the contrast in there, I was pretty happy. And it was such a big collection that I was not going to fill up the whole thing completely. But it was enough that I could see that it was pretty encapsulated, and it was a collection. It didn't look like colon at all, so I was happy. So do you think there was air in the gallbladder? Why did you enter the gallbladder? No, no, the gallbladder, I didn't enter it. I saw the gallbladder. I did not touch it, because it looked like a nice, it was a lot of fluid in there, and there were stones in there. So it looked like a nice collection that might fool you into thinking, oh, that's necrotic debris, and this is the collection that I need to drain. But it wasn't. That's not what you want to do. Don't get confused with a gallbladder and trying to drain the gallbladder. Thank you. That was awesome.

pancreatitis

abdominal pain

endoscopic ultrasound

EUS

fluoroscopy