There are a lot of situations that can arise in severe pancreatitis that are difficult to feel

100% confident about, such as what do you do with fluid collections seen on imaging? And it depends

so much on the clinical picture. Usually we try to manage them conservatively. However, sometimes

these fluid collections continue to get bigger

and cause significant pain, even to the point they can compress adjacent organs. Or we may be

concerned that the fluid has become infected because of an unexplained fever or leukocytosis

or gas in the fluid collection. Therefore, medical andoscopic or surgical intervention may become needed.

And we will come back to fluid collections.

I first want to contrast fluid collections with other processes that occur with the pancreas.

So what about pancreatic necrosis? The pancreas can do a heck of a job in

auto-digesting itself. Hypovalemia, hypotension are often the clinical signs that necrosis may be

occurring. Ultrasound is and should be the initial imaging test in nearly every patient presenting with pancreatitis

because it helps determine if gallstones are the etiology.

But ultrasound does not generally help to determine the severity of pancreatitis.

Contrast enhanced CT scan will help in determining severity, but does not need to be

done for most patients with pancreatitis. Doing an early CT in patients with mild pancreatitis,

which is most patients, just increases cancer-causing radiation and cost. You don't get much value from a CT done too early.

And let's remember, one of our key roles as hospice is to save resources

so there will be enough of the patient's money left to spend their life savings on the last month of life,

such as on the ridiculously priced novel oncology agents

that will keep them alive for an extra three weeks. Bad humor side, we also need to remember

not only the radiation risk, but since patients are volume depleted early in the course of

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