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Mo1411 Predictors of Mortality in Acute Pancreatitis in United States Hospitalized Patients, 2012
AGA Abstracts
those admitted to ICU, 55% were transferred from an OSH. Patients presenting via ER were older than transfer patients (p=0.005). Transfers were more likely to have private insurance (p=0.002). Median time to transfer was 2 days (IQR 1,5); median distance transferred, 31.7 miles (IQR 12.1,54.8). In-hospital mortality and 90-day mortality among all patients admitted to the ICU were 14.5% and 17.9%, respectively. OSH transfer was not associated with increased in-hospital (transfers14.0% vs. non-transfers 15.1% p=0.78) or 90-day (transfers 17.0% vs. non-transfers 18.9% p=0.68) mortality, but was associated with increased LOS (transfers 13 days vs. non-transfers 9 days p<0.0001) and total charges (transfers $57,769 vs. non-transfers $70,872 p=0.01). Neither time to transfer nor distance transferred were associated with increased in-hospital (p=0.92), (p=0.11) or 90-day (p=0.74), (p=0.18) mortality. Discussion: For acute pancreatitis patients, gender and age predict ICU admission. Transfer from OSH was associated with increased LOS and costs, but no statistically significant association between transfer, time to transfer or distance transferred and in hospital or 90 day mortality was demonstrated.
uncertain. Similar data are being collected prospectively to assess the benefit, if any, of management according to published guidelines. Baseline Data and Legth of Stay
* significantly different compared to severe (p < 0.05) # significantly different compared to severe (p < 0.05)
Mo1411 Predictors of Mortality in Acute Pancreatitis in United States Hospitalized Patients, 2012 Lance D. McLeroy, Brandon Wuerth, Andrew Brock Background: Acute pancreatitis (AP) is a common cause of hospitalization in the U.S. and can carry a high mortality rate, depending upon risk factors. Objective: To investigate risk factors associated with case fatality rates of AP in hospitalized patients in the United States. Design: Retrospective, observational cohort study of the Nationwide Inpatient Sample (NIS) from 2012. AP was identified in hospitalizations with a principle ICD-9-CM diagnosis of Acute Pancreatitis (577.0). Cases were stratified by risk factors including demographics along with the majority of the Ranson criteria, Apache II score, and Bisap score using ICD9 codes. The effect each risk factor had on the case fatality rate was determined using odds ratios. Results: The overall case fatality rate of hospitalized patient with AP was 0.79 deaths per 100 cases. Case fatality rates were highest in those aged 85 years or older (3.78%, OR 18.31, p<0.01), patients in the Mid-Atlantic region (1.09%, OR 2.00, P<0.01), Asians (1.12%, OR 1.28, p<0.01) and males (0.89%, OR 1.30, p<0.01). Risk factors most associated with higher case fatality rates included mechanical ventilation (26.7%, OR 107.38, p<0.01), hypotension/shock (14.13%, OR 40.55, p<0.01), acute respiratory failure (13.52%, OR 43.45, p<0.01), and SIRS (10.72%, OR 25.48, p<0.01). Risk factors that appeared to be protective were hypokalemia (0.64%, OR 0.78, p<0.01) and transaminitis (0.40%, OR 0.50, p<0.01). Risk factors that were not statistically significant were fever/hypothermia (0.79%, OR 1.00, p=0.98) and leukocytosis (0.74%, OR 0.94, p=0.50). Conclusion: Acute pancreatitis remains a common diagnosis associated with inpatient hospitalization. Certain risk factors were associated with higher case fatality rates including mechanical ventilation, hypotension, acute respiratory failure, and SIRS. Case fatality rates were highest among Asians, males, and patients over the age of 85. Fever/hypothermia and leukocytosis, despite being present in the Ranson criteria and Apache II score, were not found to significantly affect the case fatality rate. Early identification and risk stratification of patients with AP is important to be able to determine patients at need for intensive care treatment. While scoring systems such as the Ranson criteria and Apache II score can be used to predict the severity of AP, the evidence in this study indicates certain risk factors used do not significantly effect case fatality rates. Although further investigation is warranted, the results of this study may be useful in the creation of a new scoring system that more accurately predicts mortality. Case fatality rate in patients hospitalized with AP sorted by age, region, race, and gender
Mo1410 Prognostic Criteria and Initial Management of Acute Pancreatitis: A Pilot Study for Evaluation of Recently Published Guidelines Stephen L. Steele, Priyanka Acharya, Rathan Reddy, Celsio Gonzalez, Anup Kumar, Prashant Kedia, Jeffrey D. Linder, Armond Schwartz, Paul R. Tarnasky Background: Acute pancreatitis (AP) is associated with significant morbidity and mortality; up to 20% of cases are severe with a risk for fatality of >25%. It remains challenging to initially predict the ultimate severity of AP. It is not clear whether either baseline patient criteria and/or initial management affect outcomes. Recently, management guidelines (e.g. early diagnosis, initial imaging with ultrasound vs CT, appropriate fluid resuscitation), complications and clinical outcomes for AP have been well defined. There is a paucity of data regarding baseline clinical criteria, complications and clinical outcomes from patients with AP managed according to recent guidelines. The aim of this pilot study was to develop a database for AP so that baseline prognostic factors, comorbidities, initial management and outcomes for patients managed before recent guidelines can be compared to prospective data on patients managed thereafter according to guidelines. Methods: A pancreatitis database was designed to collect data specifically based on recent guidelines. Records from all pts with an admission or discharge diagnosis of AP from Nov. 2012 to Dec. 2014 were included for analysis if 2 of the 3 following criteria were met: (i) abdominal pain consistent with AP, (ii) serum amylase and/or lipase > 3X ULN, and (iii) characteristic findings on imaging. Exclusion criteria included: age < 18 yrs, transferred, post-ERCP AP, and recent trauma. Baseline prognostic data included age, BMI, WBC, Hct, BUN, harmless acute pancreatitis score (HAPS), systemic inflammatory response syndrome (SIRS), BISAP and comorbidity. Initial management data included imaging. Data at discharge, subsequent admissions and all imaging results were reviewed to determine local and systemic complications. Final outcomes were defined as mild, moderately severe and severe. Results: Data from 165 pts with AP were evaluated. The most common etiology was biliary (42%) of which 21 (13% of total) underwent ERCP. Final severity of AP was mild in 125 (76%), moderately severe in 29 (17%), and severe in 11 (7%) of which 5 died. Baseline data and LOS according to outcomes are found in Table 1. 67 pts (41%) did not have an initial US and 96 pts (58%) did not have an initial chest x-ray. 81 pts (49%) had CT scans in the ER of which 59 ultimately had only mild AP. Age, WBC, SIRS, BISAP and comorbidity were associated with outcomes but BMI, Hct, and HAPS were not. Number of ICU days was significantly associated with severity. Conclusions: Data from AP patients managed prior to published guidelines suggest a need to improve utilization of initial imaging. Some baseline clinical criteria correlated with outcome so a possible effect of initial management on outcome may be
AGA Abstracts
S-704
ROC curves of the various parameters in predicting moderately-severe or severe acute pancreatitis.
Mo1413 Case fatality rates of acute pancreatitis by risk factor, 2012 Analysis of the Step-Up Approach in the Management of Walled off Pancreatic Necrosis (WOPN) in a Large Cohort of Patients at a United States Academic Medical Center Jason D. Jones, Joshua Matrachisia, Joshua B. French, Doug Case, Clancy J. Clark, Girish Mishra, Rishi Pawa Introduction: Endoscopic and minimally invasive techniques can reduce end-organ failure, procedure-related complications, and the high mortality associated with acute necrotizing pancreatitis (ANP). However, implementation of the step-up approach, in which these techniques are employed at presentation instead of primary surgical intervention, involves the coordinated efforts of a multidisciplinary team. The aim of the current study was to evaluate clinical outcomes in patients who underwent a step-up approach for management of WOPN at a large academic medical center in the United States. Methods: All patients admitted at our institution with ANP from January 2010-March 2015 and treated with the step-up approach were analyzed. Patients in this group initially underwent endoscopic / percutaneous drainage (or both), followed by surgery if they failed to show clinical improvement. The primary clinical outcome measures evaluated were hospital length of stay (LOS) at the time of intervention and in-hospital mortality. Kaplan-Meier methods were used to estimate the LOS distributions. Fisher exact tests were used to assess the difference in categorical variables between those who did and did not fail their initial treatment. Results: From 2010 to 2015, 1,253 patients were admitted > 24 hours for acute pancreatitis and of these, 69 patients with ANP developed WOPN requiring intervention. 31 patients (44.92%) were treated with a step-up approach and 38 patients (55.07%) underwent primary surgical intervention. In the step-up group, the median age of patients was 53 years (range 35 - 77) with 67.7% of patients being male. A large majority of patients were Caucasian (90.3%) with gallstones and alcohol accounting for 48.4% of the etiology of ANP. Endoscopic drainage was used in 14 patients, percutaneous drainage in 12 patients, and dual modality drainage (endoscopic and percutaneous) in 5 patients. Infected WOPN was seen in 38.7% (n=12) of patients and an ICU stay/multisystem organ failure was observed in 32.3% (n=10) of patients in this group. The median LOS was 8 days and in-hospital mortality was 6.5%. 80.64% of patients (n=25) were successfully treated with endoscopic and/or percutaneous drainage alone. Surgery, using either video-assisted retroperitoneal debridement (VARD) or open necrosectomy, was employed in 6 patients who failed to improve with initial interventions. 83.3% (n=5) of patients requiring surgery in the step-up group had infected WOPN compared to 28% (n=7) in those who did not require surgery (p=0.022). Conclusions: The use of a step-up approach in the management of acute necrotizing pancreatitis appears to result in an in-hospital mortality less than that historically observed. Patients with infected WOPN are more likely to fail initial intervention, thus necessitating surgical intervention.
Mo1414 Mo1412 Late Presentation of Acute Pancreatitis ( Beyond 72 Hours) Is Associated With Worse Outcomes in Comparison to Early Presentation (< 72 Hours) Naresh Bhat, Pradeep Kakkadasam Ramaswamy, Amit Yelsangikar, Kayalvizhi Nagarajan, Anupama Nagar
Effect of Abdominal Fat and Muscle Distribution on Severity of Acute Pancreatitis Seung Bae Yoon, Inseok Lee, Chul-Hyun Lim, Jin Soo Kim, Yu Kyung Cho, Jae Myung Park, Bo-In Lee, Young-Seok Cho, Myung-Gyu Choi
Background & Aim: To evaluate the outcome of patients with Acute Pancreatitis (AP) who presented or were referred within 72 hrs of onset of symptom onset compared to those who presented beyond 72 hours. Methods: All patients AP who presented between June
Background and Aims: Obesity is a well-established risk factor for severe acute pancreatitis. Assuming that visceral obesity or sarcopenic obesity more directly influence the severity of acute pancreatitis, we investigated and compared the relationship between various body
S-705
AGA Abstracts
AGA Abstracts
parameters including body weight (BW), body mass index (BMI), abdominal circumference (AC), visceral fat (VF), subcutaneous fat (SF) and visceral fat-to-muscle ratio (VMR) and severe acute pancreatitis. Methods: We retrospectively analyzed data from patients who were diagnosed with acute pancreatitis from July 2009 to June 2015. Abdominal computed tomography was performed within 24 hours after admission in all patients, and AC, VF, SF, and skeletal muscle areas were measured at L3-4 intervertebral levels by image analysis software programs. The revised Atlanta classification was adopted to define the severity of acute pancreatitis. Results: Among 219 patients, 13 (5.9%) and 67 (30.6%) patients had severe or moderately-severe acute pancreatitis, and 139 (63.5%) were mild cases. VMR demonstrated the highest areas under receiver operating characteristic curves [0.735, (95% confidence interval: 0.68-0.80)] in predicting the severity of acute pancreatitis. The optimal threshold of VMR for predicting the severity of acute pancreatitis is 1. Prevalence of various complications including acute pancreatic fluid collection, acute necrotic collection, pseudocyst and organ failure were higher in the patients with VMR over 1 than those with VMR under 1 (all p<0.05). A higher VMR was also correlated with a longer duration of hospitalization (p<0.001). Conclusions: In acute pancreatitis, VMR may be the most precise predictor of severity among various body parameters. VMR over 1 shows the optimal threshold for predicting severe pancreatitis, and this simple grading system can be usefully incorporated into future predictive scoring models.
those admitted to ICU, 55% were transferred from an OSH. Patients presenting via ER were older than transfer patients (p=0.005). Transfers were more likely to have private insurance (p=0.002). Median time to transfer was 2 days (IQR 1,5); median distance transferred, 31.7 miles (IQR 12.1,54.8). In-hospital mortality and 90-day mortality among all patients admitted to the ICU were 14.5% and 17.9%, respectively. OSH transfer was not associated with increased in-hospital (transfers14.0% vs. non-transfers 15.1% p=0.78) or 90-day (transfers 17.0% vs. non-transfers 18.9% p=0.68) mortality, but was associated with increased LOS (transfers 13 days vs. non-transfers 9 days p<0.0001) and total charges (transfers $57,769 vs. non-transfers $70,872 p=0.01). Neither time to transfer nor distance transferred were associated with increased in-hospital (p=0.92), (p=0.11) or 90-day (p=0.74), (p=0.18) mortality. Discussion: For acute pancreatitis patients, gender and age predict ICU admission. Transfer from OSH was associated with increased LOS and costs, but no statistically significant association between transfer, time to transfer or distance transferred and in hospital or 90 day mortality was demonstrated.
uncertain. Similar data are being collected prospectively to assess the benefit, if any, of management according to published guidelines. Baseline Data and Legth of Stay
* significantly different compared to severe (p < 0.05) # significantly different compared to severe (p < 0.05)
Mo1411 Predictors of Mortality in Acute Pancreatitis in United States Hospitalized Patients, 2012 Lance D. McLeroy, Brandon Wuerth, Andrew Brock Background: Acute pancreatitis (AP) is a common cause of hospitalization in the U.S. and can carry a high mortality rate, depending upon risk factors. Objective: To investigate risk factors associated with case fatality rates of AP in hospitalized patients in the United States. Design: Retrospective, observational cohort study of the Nationwide Inpatient Sample (NIS) from 2012. AP was identified in hospitalizations with a principle ICD-9-CM diagnosis of Acute Pancreatitis (577.0). Cases were stratified by risk factors including demographics along with the majority of the Ranson criteria, Apache II score, and Bisap score using ICD9 codes. The effect each risk factor had on the case fatality rate was determined using odds ratios. Results: The overall case fatality rate of hospitalized patient with AP was 0.79 deaths per 100 cases. Case fatality rates were highest in those aged 85 years or older (3.78%, OR 18.31, p<0.01), patients in the Mid-Atlantic region (1.09%, OR 2.00, P<0.01), Asians (1.12%, OR 1.28, p<0.01) and males (0.89%, OR 1.30, p<0.01). Risk factors most associated with higher case fatality rates included mechanical ventilation (26.7%, OR 107.38, p<0.01), hypotension/shock (14.13%, OR 40.55, p<0.01), acute respiratory failure (13.52%, OR 43.45, p<0.01), and SIRS (10.72%, OR 25.48, p<0.01). Risk factors that appeared to be protective were hypokalemia (0.64%, OR 0.78, p<0.01) and transaminitis (0.40%, OR 0.50, p<0.01). Risk factors that were not statistically significant were fever/hypothermia (0.79%, OR 1.00, p=0.98) and leukocytosis (0.74%, OR 0.94, p=0.50). Conclusion: Acute pancreatitis remains a common diagnosis associated with inpatient hospitalization. Certain risk factors were associated with higher case fatality rates including mechanical ventilation, hypotension, acute respiratory failure, and SIRS. Case fatality rates were highest among Asians, males, and patients over the age of 85. Fever/hypothermia and leukocytosis, despite being present in the Ranson criteria and Apache II score, were not found to significantly affect the case fatality rate. Early identification and risk stratification of patients with AP is important to be able to determine patients at need for intensive care treatment. While scoring systems such as the Ranson criteria and Apache II score can be used to predict the severity of AP, the evidence in this study indicates certain risk factors used do not significantly effect case fatality rates. Although further investigation is warranted, the results of this study may be useful in the creation of a new scoring system that more accurately predicts mortality. Case fatality rate in patients hospitalized with AP sorted by age, region, race, and gender
Mo1410 Prognostic Criteria and Initial Management of Acute Pancreatitis: A Pilot Study for Evaluation of Recently Published Guidelines Stephen L. Steele, Priyanka Acharya, Rathan Reddy, Celsio Gonzalez, Anup Kumar, Prashant Kedia, Jeffrey D. Linder, Armond Schwartz, Paul R. Tarnasky Background: Acute pancreatitis (AP) is associated with significant morbidity and mortality; up to 20% of cases are severe with a risk for fatality of >25%. It remains challenging to initially predict the ultimate severity of AP. It is not clear whether either baseline patient criteria and/or initial management affect outcomes. Recently, management guidelines (e.g. early diagnosis, initial imaging with ultrasound vs CT, appropriate fluid resuscitation), complications and clinical outcomes for AP have been well defined. There is a paucity of data regarding baseline clinical criteria, complications and clinical outcomes from patients with AP managed according to recent guidelines. The aim of this pilot study was to develop a database for AP so that baseline prognostic factors, comorbidities, initial management and outcomes for patients managed before recent guidelines can be compared to prospective data on patients managed thereafter according to guidelines. Methods: A pancreatitis database was designed to collect data specifically based on recent guidelines. Records from all pts with an admission or discharge diagnosis of AP from Nov. 2012 to Dec. 2014 were included for analysis if 2 of the 3 following criteria were met: (i) abdominal pain consistent with AP, (ii) serum amylase and/or lipase > 3X ULN, and (iii) characteristic findings on imaging. Exclusion criteria included: age < 18 yrs, transferred, post-ERCP AP, and recent trauma. Baseline prognostic data included age, BMI, WBC, Hct, BUN, harmless acute pancreatitis score (HAPS), systemic inflammatory response syndrome (SIRS), BISAP and comorbidity. Initial management data included imaging. Data at discharge, subsequent admissions and all imaging results were reviewed to determine local and systemic complications. Final outcomes were defined as mild, moderately severe and severe. Results: Data from 165 pts with AP were evaluated. The most common etiology was biliary (42%) of which 21 (13% of total) underwent ERCP. Final severity of AP was mild in 125 (76%), moderately severe in 29 (17%), and severe in 11 (7%) of which 5 died. Baseline data and LOS according to outcomes are found in Table 1. 67 pts (41%) did not have an initial US and 96 pts (58%) did not have an initial chest x-ray. 81 pts (49%) had CT scans in the ER of which 59 ultimately had only mild AP. Age, WBC, SIRS, BISAP and comorbidity were associated with outcomes but BMI, Hct, and HAPS were not. Number of ICU days was significantly associated with severity. Conclusions: Data from AP patients managed prior to published guidelines suggest a need to improve utilization of initial imaging. Some baseline clinical criteria correlated with outcome so a possible effect of initial management on outcome may be
AGA Abstracts
S-704
ROC curves of the various parameters in predicting moderately-severe or severe acute pancreatitis.
Mo1413 Case fatality rates of acute pancreatitis by risk factor, 2012 Analysis of the Step-Up Approach in the Management of Walled off Pancreatic Necrosis (WOPN) in a Large Cohort of Patients at a United States Academic Medical Center Jason D. Jones, Joshua Matrachisia, Joshua B. French, Doug Case, Clancy J. Clark, Girish Mishra, Rishi Pawa Introduction: Endoscopic and minimally invasive techniques can reduce end-organ failure, procedure-related complications, and the high mortality associated with acute necrotizing pancreatitis (ANP). However, implementation of the step-up approach, in which these techniques are employed at presentation instead of primary surgical intervention, involves the coordinated efforts of a multidisciplinary team. The aim of the current study was to evaluate clinical outcomes in patients who underwent a step-up approach for management of WOPN at a large academic medical center in the United States. Methods: All patients admitted at our institution with ANP from January 2010-March 2015 and treated with the step-up approach were analyzed. Patients in this group initially underwent endoscopic / percutaneous drainage (or both), followed by surgery if they failed to show clinical improvement. The primary clinical outcome measures evaluated were hospital length of stay (LOS) at the time of intervention and in-hospital mortality. Kaplan-Meier methods were used to estimate the LOS distributions. Fisher exact tests were used to assess the difference in categorical variables between those who did and did not fail their initial treatment. Results: From 2010 to 2015, 1,253 patients were admitted > 24 hours for acute pancreatitis and of these, 69 patients with ANP developed WOPN requiring intervention. 31 patients (44.92%) were treated with a step-up approach and 38 patients (55.07%) underwent primary surgical intervention. In the step-up group, the median age of patients was 53 years (range 35 - 77) with 67.7% of patients being male. A large majority of patients were Caucasian (90.3%) with gallstones and alcohol accounting for 48.4% of the etiology of ANP. Endoscopic drainage was used in 14 patients, percutaneous drainage in 12 patients, and dual modality drainage (endoscopic and percutaneous) in 5 patients. Infected WOPN was seen in 38.7% (n=12) of patients and an ICU stay/multisystem organ failure was observed in 32.3% (n=10) of patients in this group. The median LOS was 8 days and in-hospital mortality was 6.5%. 80.64% of patients (n=25) were successfully treated with endoscopic and/or percutaneous drainage alone. Surgery, using either video-assisted retroperitoneal debridement (VARD) or open necrosectomy, was employed in 6 patients who failed to improve with initial interventions. 83.3% (n=5) of patients requiring surgery in the step-up group had infected WOPN compared to 28% (n=7) in those who did not require surgery (p=0.022). Conclusions: The use of a step-up approach in the management of acute necrotizing pancreatitis appears to result in an in-hospital mortality less than that historically observed. Patients with infected WOPN are more likely to fail initial intervention, thus necessitating surgical intervention.
Mo1414 Mo1412 Late Presentation of Acute Pancreatitis ( Beyond 72 Hours) Is Associated With Worse Outcomes in Comparison to Early Presentation (< 72 Hours) Naresh Bhat, Pradeep Kakkadasam Ramaswamy, Amit Yelsangikar, Kayalvizhi Nagarajan, Anupama Nagar
Effect of Abdominal Fat and Muscle Distribution on Severity of Acute Pancreatitis Seung Bae Yoon, Inseok Lee, Chul-Hyun Lim, Jin Soo Kim, Yu Kyung Cho, Jae Myung Park, Bo-In Lee, Young-Seok Cho, Myung-Gyu Choi
Background & Aim: To evaluate the outcome of patients with Acute Pancreatitis (AP) who presented or were referred within 72 hrs of onset of symptom onset compared to those who presented beyond 72 hours. Methods: All patients AP who presented between June
Background and Aims: Obesity is a well-established risk factor for severe acute pancreatitis. Assuming that visceral obesity or sarcopenic obesity more directly influence the severity of acute pancreatitis, we investigated and compared the relationship between various body
S-705
AGA Abstracts
AGA Abstracts
parameters including body weight (BW), body mass index (BMI), abdominal circumference (AC), visceral fat (VF), subcutaneous fat (SF) and visceral fat-to-muscle ratio (VMR) and severe acute pancreatitis. Methods: We retrospectively analyzed data from patients who were diagnosed with acute pancreatitis from July 2009 to June 2015. Abdominal computed tomography was performed within 24 hours after admission in all patients, and AC, VF, SF, and skeletal muscle areas were measured at L3-4 intervertebral levels by image analysis software programs. The revised Atlanta classification was adopted to define the severity of acute pancreatitis. Results: Among 219 patients, 13 (5.9%) and 67 (30.6%) patients had severe or moderately-severe acute pancreatitis, and 139 (63.5%) were mild cases. VMR demonstrated the highest areas under receiver operating characteristic curves [0.735, (95% confidence interval: 0.68-0.80)] in predicting the severity of acute pancreatitis. The optimal threshold of VMR for predicting the severity of acute pancreatitis is 1. Prevalence of various complications including acute pancreatic fluid collection, acute necrotic collection, pseudocyst and organ failure were higher in the patients with VMR over 1 than those with VMR under 1 (all p<0.05). A higher VMR was also correlated with a longer duration of hospitalization (p<0.001). Conclusions: In acute pancreatitis, VMR may be the most precise predictor of severity among various body parameters. VMR over 1 shows the optimal threshold for predicting severe pancreatitis, and this simple grading system can be usefully incorporated into future predictive scoring models.