Management of pancreatic fluid collections: A comprehensive review of the literature

Pancreatic fluid collections(PFCs) are a frequent complication of pancreatitis. It is important to classify PFCs to guide management. The revised Atlanta criteria classifies PFCs as acute or chronic, with chronic fluid collections subdivided into pseudocysts and walled-off pancreatic necrosis(WOPN). Establishing adequate nutritional support is an essential step in the management of PFCs. Early attempts at oral feeding can be trialed in patients with mild pancreatitis. Enteral feeding should be implemented in patients with moderate to severe pancreatitis. Jejunal feeding remains the preferred route of enteral nutrition. Symptomatic PFCs require drainage; options include surgical, percutaneous, or endoscopic approaches. With the advent of newer and more advanced endoscopic tools and expertise, and an associated reduction in health care costs, minimally invasive endoscopic drainage has become the preferable approach. An endoscopic ultrasonography-guided approach using a seldinger technique is the preferred endoscopic approach. Both plastic stents and metal stents are efficacious and safe; however, metal stents may offer an advantage, especially in infected pseudocysts and in WOPN. Direct endoscopic necrosectomy is often required in WOPN. Lumen apposing metal stents that allow for direct endoscopic necrosectomy and debridement through the stent lumen are preferred in these patients. Endoscopic retrograde cholangio pancreatography with pancreatic duct(PD) exploration should be performed concurrent to PFC drainage. PD disruption is associated with an increased severity of pancreatitis, an increased risk of recurrent attacks of pancreatitis and long-term complications, and a decreased rate of PFC resolution after drainage. Any pancreatic ductal disruption should be bridged with endoscopic stenting.

SARS-COV-2 infection(coronavirus disease 2019)for the gastrointestinal consultant

The current pandemic due to the severe acute respiratory syndrome coronavirus 2 has caused an extreme burden for health care systems globally,and the number of cases is expected to continue to increase,at least in the immediate future.The virus is estimated to have infected more than 1.5 million individuals.The available reports suggest that gastrointestinal(GI)involvement in coronavirus disease 2019(COVID-19)is common and in some cases the GI symptoms may precede the respiratory symptoms.In addition to direct effects of severe acute respiratory syndrome coronavirus 2,the infected patients remain at risk for the complications commonly managed by gastroenterology and hepatology consultants.The most commonly reported GI manifestation of COVID-19 is diarrhea,which is reported in a third to up to more than half of the patients.Mild to moderate elevation of the liver enzymes are also common,although no case of acute liver failure has been reported so far.Many of the medications used for treatment of COVID-19 can also be associated with GI symptoms or liver injury and can be included in the differential diagnosis in these patients.Although the diagnosis of the infection is currently based on RNA analysis in respiratory samples,the available literature on fecal shedding of this virus suggests that fecal RNA testing might prove to be a useful diagnostic test.It is reasonable to delay all non-urgent endoscopic procedures during the peak of the pandemic and use additional protective equipment such as N95 respirators during endoscopy while most patients can be considered high risk for having been exposed to the virus.