Category: Gastrointestional
Posted: 8/13/2024 by Neeraja Murali, DO, MPH
(Emailed: 8/14/2024)
(Updated: 8/14/2024)
Click here to contact Neeraja Murali, DO, MPH
This study, done out of Australia, examined the association between abdominal pain and severity of liver injury in patients presenting after acute acetaminophen overdose.
539 cases were identified where N-acetylcysteine was administered to patients with acetaminophen overdose. The investigators explored parameters including presence of abdominal pain, time post-ingestion, and peak ALT.
Patients less than 8 hours post overdose WITH abdominal pain were as likely to develop hepatotoxicity as those presenting WITHOUT abdominal pain. (OR=1.18 [0.07 to 19.4])
Patients presenting 8 or more hours post overdose WITH abdominal pain were as likely to develop hepatotoxicity as those WITHOUT abdominal pain (OR=1.28 [0.39 to 4.21])
Don't let lack of pain fool you! Just as we all learned in medical school - let your history be your guide!
Wang C, Wong A. The presence of abdominal pain associated with acetaminophen overdose does not predict severity of liver injury. Am J Emerg Med. 2024;79:52-57. doi:10.1016/j.ajem.2024.02.011
Category: Gastrointestional
Keywords: analgesia (PubMed Search)
Posted: 7/10/2024 by Neeraja Murali, DO, MPH
(Updated: 9/7/2024)
Click here to contact Neeraja Murali, DO, MPH
I don't know about you, but I'm always eager to hear new and alternative methods of pain control…
This study examined the effectiveness of transcutaneous electrical nerve stilumlation (TENS) in patients with abdominal pain. Patients were randomized to TENS or sham applied to the abdomen. The primary outcome of interest was change in pain score 30 min after the intervention, and secondary outcome was percentage of patients requiring rescue analgesia. Pain scores were measured on a verbal numeric score scale with a range from 0 to 10, with any adult patients with a minimum score of 5 being eligible.
The mean reductions in pain scores after the intervention were also similar in patients treated with TENS and sham TENS (1.9 vs. 1.7 respectively, p = 0.81). THe use of rescue analgesia was 49% in patients treated with TENS and 51% in those who received sham TENS (p=0.66). No adverse events were noted.
The authors did note that there is a challenge in blinding due to toeh absence of electrical stimulation in the sham group; nonetheless, TENS was not found to be more effective than sham. It also did not reduce the need to rescue analgesia.
Guess I'll keep looking…
McMahon B, Prabhu A, Thode HC Jr, Singer A. Transcutaneous electrical nerve stimulation (TENS) versus sham TENS in adult ED patients with abdominal pain: A clinical trial. Am J Emerg Med. 2024;76:7-12. doi:10.1016/j.ajem.2023.10.035
Category: Gastrointestional
Keywords: antibiotics appendicitis (PubMed Search)
Posted: 6/12/2024 by Neeraja Murali, DO, MPH
(Updated: 9/7/2024)
Click here to contact Neeraja Murali, DO, MPH
By now, most of us are aware that there's evidence supporting the use of an antibiotics-only approach for acute uncomplicated appendicitis. One of the major trials evaluating this is the Appendicitis Acuta II Trial. Our paper today continued longitudinal follow up of the original cohort enrolled in this study.
Patients were randomized to receive either oral antibiotic monotherapy (moxifloxacin 400 mg/d x 7 days) or IV and oral antibiotics (IV ertapenem 1 g/d x 2 days plus oral levofloxacin 500 mg/d + metronidazole500 mg q8h x 5 d).
Primary endpoint: resolution of acute appendicitis and hospital discharge without surgery and no reoccurence at time of follow up (3 years later).
There were 582 patients in the three year follow up cohort; Success was 63.4% (1-sided 95% CI, 58.8% to ?) in the oral antibiotics only group and 65.2% in the IV + oral antibiotics(1-sided 95% CI, 60.5% to ?). The difference in success rate was -1.8% (1-sided 95% CI, ?8.3 percentage points to ?; P?=?.14 for noninferiority).
No significant difference in secondary endpoints, including treatment-related adverse events, quality of life, length of hospital stay, and length of sick leave.
In this secondary analysis of the three year cohort from the APPAC II trial, there was a slightly higher appendectomy rate in patients who received oral antibiotic therapy; noninferiority of this regimen (as composed to combined) could not be demonstrated.
Selänne L, Haijanen J, Sippola S, et al. Three-Year Outcomes of Oral Antibiotics vs Intravenous and Oral Antibiotics for Uncomplicated Acute Appendicitis: A Secondary Analysis of the APPAC II Randomized Clinical Trial. JAMA Surg. Published online April 17, 2024. doi:10.1001/jamasurg.2023.5947
Category: Gastrointestional
Keywords: CT, contrast (PubMed Search)
Posted: 5/8/2024 by Neeraja Murali, DO, MPH
(Updated: 9/7/2024)
Click here to contact Neeraja Murali, DO, MPH
Oftentimes, CT imaging is used in diagnosis of emergent abdominal pathology. However, there may be instances where there is hesitancy to use IV contrast, whether due to patient factors or extrinsic factors (remember the contrast shortage during covid?)
This study examines the diagnostic accuracy of dry CT. 3 quaternary centers with residency training programs participated, and contrasted images underwent further processing to remove any IV or oral contrast. Both residents and faculty reviewed the images, and findings were compared to both the initial read by radiologist as well as independent reads by a panel of experts. They looked for both primary findings (those that explained the abdominal pain) as well as actionable secondary findings (ie incidental findings requiring additional imaging or further management).
When compared to contasted imaging, the accuracy of dry CT was 70% (faculty, 68% to 74%; residents, 69% to 70%). Faculty had higher accuracy than residents for primary diagnoses but lower accuracy for actionable secondary diagnoses.
Thus when considering the necessity of contrast, please consider the potential for missed diagnosis.
Shaish H, Ream J, Huang C, et al. Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department. JAMA Surg. 2023;158(7):e231112. doi:10.1001/jamasurg.2023.1112
Category: Gastrointestional
Keywords: ED recidivism, abdominal pain, follow up appointments (PubMed Search)
Posted: 2/14/2024 by Neeraja Murali, DO, MPH
(Updated: 9/7/2024)
Click here to contact Neeraja Murali, DO, MPH
How many times have you discharged a patient with a clinical impression of “abdominal pain” with no clear explanation or diagnosis?
How many of these times do you direct them to follow up with gastroenterology? And more importantly, how often do they actually do so?
This study discussed a multi-disciplinary approach to ensuring adequate follow up for patients, utilizing an EMR based transition of care (TOC) program. The study stratified patients into 2 groups, pre and post TOC program implementation, to assess rates of appointment scheduling and attendance, as well as rates of return to ED within 30 days. Patients were further stratified based on their Distressed Communities Index (DCI) score (a composite of 7 different socioeconomic metrics) into 5 tiers: Distressed Communities, At Risk Communities, Mid-Tier Communities, Comfortable Communities, and Prosperous Communities. Prior to the implementation of the TOC program, the onus was on the patient to schedule their appointment. The TOC program consisted of an order placed in EMR, which triggered review of the patient's chart by the gastroenterology attending or NP. This individual would then message the information to the appropriate GI subspecialty clinic, along with a time frame in which the patient should be seen. The clinic would then check the patient's insurance reach out to the patient directly to schedule the appointment.
While there was no signifcant difference in 30-day readmission between the pre and post TOC program patients, the post-implementation group was found to both schedule appointments (50% vs 27% p-value <0.01) AND show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. Additionally, post-TOC patients in the At-Risk and Distressed DCI groups were 22x more likely to follow up than the same groups in the pre-TOC group (OR 22.18, 95% CI 4.23–116.32).
Though the study had promising results, it did admittedly have some limitations, namely the size of the at-risk and distressed groups. Another consideration, though not mentioned in the paper, is that access to a working phone is necessary to the success of this program. Nevertheless, the idea of a TOC program is worth consideration as a means to ensure that patients are not lost to follow up and potentially reduce the risk of adverse events.
Mizrahi J, Marhaba J, Buniak W, Sun E. Transition-of-care program from emergency department to gastroenterology clinics improves follow-up. Am J Emerg Med. 2023;69:154-159. doi:10.1016/j.ajem.2023.04.030
Category: Gastrointestional
Posted: 1/10/2024 by Neeraja Murali, DO, MPH
(Updated: 9/7/2024)
Click here to contact Neeraja Murali, DO, MPH
This retrospective cohort study examined patients over a one year period to evaluate factors associated with unfavorable outcomes in acute abdominal pain.
Unfavorable outcomes were defined as any of the following: 1) shock requiring an invasive procedure such as central line insertion or mechanical ventilation 2) emergency surgery 3) post-operative complications OR 4) in-hospital cardiac arrest
951 patients were included in the study.
Physical exam and laboratory signs associated with the above unfavorable outcomes included:
-diastolic BP < 80 mmHG
-RR ? 24/min
-RLQ tenderness
-abd distension
-hypoactive bowel sounds
-presence of specific abdominal signs (ie Murphy's sign, psoas sign, etc).
-leukocytosis
-ANC >75%
Further, ED Length of Stay of > 4 hours was also associated with unfavorable outcomes.
Food for thought when considering serial abdominal exams when diagnosis is unclear…
Dadeh AA. Factors associated with unfavorable outcomes in patients with acute abdominal pain visiting the emergency department. BMC Emerg Med. 2022 Dec 6;22(1):195. doi: 10.1186/s12873-022-00761-y. PMID: 36474160; PMCID: PMC9727909.
Category: Gastrointestional
Keywords: NG Tube (PubMed Search)
Posted: 11/9/2023 by Neeraja Murali, DO, MPH
Click here to contact Neeraja Murali, DO, MPH
Think before placing a nasogastric tube!
Multiple articles which discussed complications of NGT placement were included in this integrative review, with the majority (n=67) publishing results in English. The authors categorized adverse events into two broad categories:
1) Mechanical adverse events - including respiratory, esophageal, and pharyngeal complications, obstructed tube, intestinal and intracranial (!) perforation, and tube withdrawal
-The largest cohort (n=44) was respiratory, with displacement or placement of tube to the respiratory tract
2) Others - pressure injury and misconnection
-One study showed pressure related injury in 25%, and 5 articles discussed complications of misconnection (including extravasation of gastric fluids and inadvertent connection to central venous catheters)
16 of the 69 studies reported death as a consequence of improper placement.
One big takeaway: there is no universally accepted standard for verificaiton of tube placement. Xray is considered to be *most* accurate. Tubes should also be checked periodically and depth should be marked. Evidence-based guidelines need to be developed to improve patient safety, outcomes, and quality of care.
Motta APG, Rigobello MCG, Silveira RCCP, Gimenes FRE. Nasogastric/nasoenteric tube-related adverse events: an integrative review. Rev Lat Am Enfermagem. 2021 Jan 8;29:e3400. doi: 10.1590/1518-8345.3355.3400. PMID: 33439952; PMCID: PMC7798396.
Category: Gastrointestional
Keywords: acute diverticulitis (PubMed Search)
Posted: 10/11/2023 by Neeraja Murali, DO, MPH
(Updated: 9/7/2024)
Click here to contact Neeraja Murali, DO, MPH
Diverticular disease is a common condition, with 60% of individuals over age 80 and 30% of those over age 45 (!) having diverticula. Recent estimates show that 10-25% of this subset with suffer at least one episode of acute diverticulitis in their lifetime. Fortunately, the majority of these cases are uncomplicated. This study provides evidence that outpatient treatment of acute diverticulitis is reasonable.
Study Design:
The DINAMO study was a multicenter randomized open-label non-inferiority trial evaluating the utility of antitbiotics in uncomplicated diverticulitis. The study included adult patients with uncomplicated diverticulitis without significant comorbities. The diagnosis was based on modified Neff classification with patients with a mNeff of 0 being included. Eligible patients were randomized to one of two treatment groups:
1) 600 mg ibuprofen q 8 h alternating with 1000 mg of acetaminophen q 8 h x7 d (Exerimental arm) OR
2) 875/125 mg amoxicillin/clavulanate q 8 h x 7 d in addition to the above (Control arm)
Outcomes of interest and Results:
Any patients who returned to the hospital underwent repeat CT. Primary of outcome of interest was admission to the hospital on revisit, with secondary outcomes being revisit itself, follow up, pain control, and recovery
There was no statistically significant difference in any of these (for numbers, please refer to article 1 linked below); further, no patients required emergency surgery.
Implications:
There is a low likelihood ot treatment failure when antibiotics are avoided in acute uncomplicated diverticulitis. This study finds this treatment regimen ot be noninferior to antibiotic treatment in terms of hospital admission, revisit rates, and recovery. Consider this treatment regimen in eligible patients.
https://journals.lww.com/annalsofsurgery/fulltext/2021/11000/efficacy_and_safety_of_nonantibiotic_outpatient.37.aspx
https://onlinelibrary.wiley.com/doi/10.1111/codi.12449
Category: Gastrointestional
Keywords: appendicitis, delayed operating room, appendectomy (PubMed Search)
Posted: 9/17/2023 by Robert Flint, MD
(Updated: 9/7/2024)
Click here to contact Robert Flint, MD
This Scandinavian study from the Lancet says yes. They randomized 1800 patients over age 18 to appendectomy either within 8 hours or 24 hours and found no difference in perforation rate or other complications.
Karoliina Jalava, Ville Sallinen, Hanna Lampela, Hanna Malmi, Ingeborg Steinholt, Knut Magne Augestad, Ari Leppäniemi, Panu Mentula,
Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial,
The Lancet, 2023
Category: Gastrointestional
Keywords: Appendicitis (PubMed Search)
Posted: 8/13/2023 by Neeraja Murali, DO, MPH
(Updated: 9/7/2024)
Click here to contact Neeraja Murali, DO, MPH
In recent years, there has been an uptick in non-operative management of acute appendicitis. This study examins outcomes in older patients (>65 years old).
The study authors evaluated retrospective data and included 474845 patients in the US with acute uncomplicated appendicitis betwen 10/2021 and 04/2022. All participants survived at least 24 hours postoperatively and none carried a diagnosis of inflammatory bowel disease; there were 43,846 patients treated nonoperatively and 430,999 who underwent appendectomy. The primary outcome was incidence of post-treatment complications, with secondary outcomes of mortality, length of stay, and inpatient costs.
In patients 65+, there was a 3.72% decrease in risk of complications, 1.82% increase in mortality, and increased LOS and costs.
Ultimately, operative management of acute appendicits was associated with reduced mortality, length of stay, and costs across all adult patients. While nonoperative management remains an option in the treatment of acute appendicits, surgical management continues to be the accepted standard.
Meier J, Stevens A, Bhat A, Berger M, Balentine C. Outcomes of Nonoperative vs Operative Management of Acute Appendicitis in Older Adults in the US. JAMA Surg. 2023;158(6):625–632. doi:10.1001/jamasurg.2023.0284
Category: Gastrointestional
Keywords: POCUS, Appendicitis, Pregnancy (PubMed Search)
Posted: 7/3/2023 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD
POCUS can be used to screen for appendicitis.
A recent study showed a sensitivity of 66.7% (CI 95% 47.1–82.7), and a specificity of 96.8% (CI 95% 83.3–99.9) during pregnancy, with the highest sensitivity in the first trimester.
2 methods to locate the appendix are:
1) have your patient point to the area where it hurts the most
2) perform a lawnmower technique over the right lower quadrant looking for the right psoas mucle and the iliac vessels. The appendix will usually be near these structures.
Sometimes it is easiest to use your curvilinear probe to identify an area of inflammation and then change to the linear probe for better visualization.
On ultrasound, appendicitis is defined as a non-compressible blind pouch with an outer diameter greater than 6 mm. On short axis the inflammed appendix will look like a target sign:
Abgottspon D, Putora K, Kinkel J, Süveg K, Widmann B, Hornung R, Minotti B. Accuracy of Point-of-care Ultrasound in Diagnosing Acute Appendicitis During Pregnancy. West J Emerg Med. 2022 Oct 23;23(6):913-918. doi: 10.5811/westjem.2022.8.56638
Category: Gastrointestional
Keywords: cannabis hyperemesis syndrome (PubMed Search)
Posted: 5/10/2023 by Neeraja Murali, DO, MPH
Click here to contact Neeraja Murali, DO, MPH
Bottom Line: With the increasing acceptance and legalization of marijuana and its derivatives, emergency departments have seen an increase in patients with cannabis hyperemesis syndrome (CHS). In this patient population, when other pathologies have been excluded, consider droperidol (0.625 mg – 2.5 mg) or haloperidol (0.05 mg/kg or 0.1 mg/kg) for management of symptoms.
Two separate articles were reviewed for this pearl. One is a systematic review of existing literature, and the other is a randomized controlled trial.
The systematic review examined 17 existing studies, including case reports, RCTs, retrospective studies, and other systematic reviews. This included adults aged 18-85 who were using recreational or medicinal cannabinoids. There was a consensus that cessation of cannabinoid use is the best way to alleviate symptoms of CHS. Other options discussed include:
As mentioned above, the HaVOC study examined various doses of haloperidol versus odansetron. This randomized controlled trial was triple blinded and had three groups: haloperidol 0.05 mg/kg or 0.1 mg/kg or odansetron 8 mg IV. The outcome of interest was reduction in abdominal pain and nausea at two hours after treatment. Either dose of haloperidol was found to be superior to odansetron, with improvements in pain and nausea (54% versus 29%; 95% CI -16% to 59%), and less use of rescue antiemetics (31% versus 59%, with 95% CI -61% to 13%). Haloperidol also resulted in shorter ED length of stay (3.1 h vs 5.6 h, 95% CI 0.1-5.0 h, p=0.03). However, 2 patients in the high dose haloperidol group had dystonic reactions precipitating return visits. The study does not specifically discuss differences in outcomes between the high and lower dose haloperidol groups.
Neither paper discussed the best alternatives when QTc prolongation is of concern. Clinicians should use their best judgment and the available information when deciding on a treatment option.
Senderovich H, Patel P, Jimenez Lopez B, Waicus S. A Systematic Review on Cannabis Hyperemesis Syndrome and Its Management Options. Med Princ Pract. 2022;31(1):29-38. doi:10.1159/000520417
Ruberto AJ, Sivilotti MLA, Forrester S, Hall AK, Crawford FM, Day AG. Intravenous Haloperidol Versus Ondansetron for Cannabis Hyperemesis Syndrome (HaVOC): A Randomized, Controlled Trial. Ann Emerg Med. 2021;77(6):613-619. doi:10.1016/j.annemergmed.2020.08.021
Category: Gastrointestional
Keywords: PPI, Gi bleed (PubMed Search)
Posted: 7/22/2018 by Michael Bond, MD
Click here to contact Michael Bond, MD
Bottom Line:
Continuous vs intermittent dosing of PPIs in bleeding peptic ulcer disease
There continues to be debate as to the optimal dose, frequency, and route of proton pump inhibitors (PPIs) in bleeding ulcers, especially prior to endoscopy. Multiple guidelines including from the American Journal of Gastroenterology continue to recommend continuous dosing of PPIs.1,2,3 However, multiple studies appear to show at least non-inferiority when compared with intermittent dosing of PPIs.
The most frequently cited study for non-inferiority is a meta-analysis of 13 randomized control trials by Sachar et al. which evaluated PPI use in patients presenting with upper GI bleeds who were endoscopically found to have a bleeding gastric or duodenal ulcer with high risk features (active bleeding, non-bleeding visible vessel, or adherent clot)4. There was non-inferiority of intermittent dosing in rebleeding, need for repeat endoscopy/surgery, RBC transfusions, and mortality with a non-statistically significant trend towards superiority of intermittent dosing.
However, the patients were only randomized to continuous vs intermittent dosing AFTER endoscopic treatment. In addition, the dosing regimen of intermittent dosing was quite variable.
Continuous dosing:
Intermittent dosing:
Bottom Line:
References:
Category: Gastrointestional
Posted: 10/21/2017 by Michael Bond, MD
(Updated: 9/7/2024)
Click here to contact Michael Bond, MD
Infectious Diarrhea:
Have your wondered what you should do with patients that you suspect have infectious diarrhea. Well the IDSA has updated their 2001 guidelines for the management of infectious diarrhea. The TAKE HOME Points are:
You can find all the recommendations at https://academic.oup.com/cid/article/doi/10.1093/cid/cix669/4557073/2017-Infectious-Diseases-Society-of-America
Category: Gastrointestional
Keywords: Gastroparesis, haloperidol (PubMed Search)
Posted: 8/5/2017 by Ashley Martinelli
Click here to contact Ashley Martinelli
Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements.
In Depth:
Study Design: single-center, retrospective review, case-matched to prior visit for gastroparesis
Patients:
52 patients with previously diagnosed diabetic gastroparesis by gastric motility study who presented to the ED for gastroparesis treatment
Groups:
Haloperidol administered visit
Haloperidol NOT administered visit (most recent visit, >7 days prior to haloperidol visit)
Results:
Baseline characteristics: median age 32 (21-57), 62% (32/52) female
Statistically significant reduction in hospital admissions for the haloperidol visit: (5/52 [10%] [CI 3-21%]) vs the non-haloperidol visit (14/52 [27%] [CI 16-41%]) p=0.02
Statistically significant reduction in opioid administration during the haloperidol visit: 6.75 ME (IQR 7.93) vs 10.75 ME (IQR 12) p=0.009
No difference in ED LOS, hospital LOS or need for additional antiemetics/prokinetics
No dystonic reactions, akathesia, excessive sedation, or cardiovascular complications in patients who received haloperidol
Limitations:
Small, single-center, retrospective study that only included patients with diabetic gastroparesis
Only intramuscular administration was studied
Baseline QT not reported
Young patient population, no description of comorbidities or home medications
Conclusions:
Haloperidol may be considered as an adjunctive therapy in patients with diabetic gastroparesis for its antiemetic and analgesic properties. Prospective studies are necessary to confirm findings.
Ramirez R, Salcup P, Croft B, Darracq MA. Am J Emerg Med 2017;35:1118-1120.
Category: Gastrointestional
Keywords: Diverticular, bleeding, gastrointestinal (PubMed Search)
Posted: 7/3/2010 by Michael Bond, MD
Click here to contact Michael Bond, MD
Diverticular Bleeding
Category: Gastrointestional
Posted: 3/22/2010 by Rob Rogers, MD
(Updated: 9/7/2024)
Click here to contact Rob Rogers, MD
Complications of Liver Biopsy
Some considerations for the patient who presents with pain after a liver biopsy:
Consider getting a chest xray and a RUQ ultrasound to evaluate for these complications if they show up in the ED. CT scanning might also be required.
Also consider getting Interventional Radiology involved early in cases of bleeding as this is often the preferred treatment for biopsy site bleeding. In addition, a surgical consult is wise
in case the patient requires operative intervention.
Category: Gastrointestional
Keywords: PEG Tubes (PubMed Search)
Posted: 10/3/2009 by Michael Bond, MD
Click here to contact Michael Bond, MD
I am sure everybody has received a patient from a nursing home that had a malfunctioning PEG tube. Now if they would only crush the tablets before putting them down the tube, or better yet use liquid medications our life would be easier.
But what do you do if it is Friday and the GI lab is not open to Monday. The answer is that you can remove the PEG and replace it with another PEG tube or even a foley catheter will do for the weekend. The original PEG tube has a semi-rigid plastic ring (as shown in photo) and does not have a balloon that can be default. You can pull these out by placing counter traction on the abdominal wall and pulling with steady firm pressure. This may take a little more force than you are initially comfortable with.
Please see the attached photo of a PEG tube, and remember the other option is to admit these patients for IV fluids until the GI lab opens.
Photo taken from the Mount Littany Wellness library that can be accessed at http://www.mountnittany.org/wellness-library/healthsheets/documents?ID=6890
Category: Gastrointestional
Keywords: HIDA, narcotics, biliary colic (PubMed Search)
Posted: 8/30/2008 by Michael Bond, MD
(Updated: 9/7/2024)
Click here to contact Michael Bond, MD
Biliary Colic and Narcotics:
It is common to give patients with biliary colic narcotics inorder to relieve their pain. It was common teaching in the past that Morphine should be avoided due to the fact that it could cause spasm of the spincter of Oddi. It is now known that all narcotics, even meperidine, can cause spasm or irritation of the spincter of Oddi.
So this weeks pearls are:
Category: Gastrointestional
Keywords: Pancreatitis (PubMed Search)
Posted: 4/12/2008 by Michael Bond, MD
(Updated: 9/7/2024)
Click here to contact Michael Bond, MD
Some simple facts about Pancreatitis: