- Email: [email protected]
Mo1424 Predictors of In-Hospital Mortality in Acute Pancreatitis
AGA Abstracts
hospitalized patients with AP, and (b) to identify factors that predict mortality, hospital associated complications (HAC) and patient safety indicators (PSI) in patients hospitalized for AP and receiving PN. METHODS: The Nationwide Inpatient Sample (2008-2012) was reviewed to determine all adult patients ( ‡18 years) with a principle diagnosis of AP. The primary clinical outcomes were mortality, HAC, and PSI, while the secondary resource outcomes included length of hospital stay and hospital charges. Univariate and multivariate comparisons in patients with and without the use of PN followed by subgroup analysis among patients receiving PN were performed. RESULTS: PN use was associated with 4.1% (37,476/893,567) of all AP admissions. Importantly, the use of PN in patients hospitalized with AP has significantly declined from 2008 to 2012 (4.5% vs. 3.4%; P<0.001). Multivariate analysis revealed that PN use was independently associated with mortality in AP (odds ratio (OR) 1.3; 95% confidence interval (CI) 1.08, 1.63; P<0.01), any HAC (OR 1.6; 95% CI 1.4, 1.8; P<0.001), and PSI (OR 3.6; 95% CI 3.3, 3.8; P<0.001). Further, PN was independently associated with prolonged length of hospital stay (by 6.9 days; 95% CI 6.6, 7.2; P<0.001), and greater hospital charges ($13,160; 95% CI $12,328, $13,992; P<0.001). Subgroup multivariate analysis among patients who received PN revealed that increasing age (OR 1.1; 95% CI 1.05, 1.07; P<0.001), acute kidney injury (OR 4.0, 95% CI 3.3, 4.8; P<0.001), respiratory failure (OR 3.1, 95% CI 2.4, 3.9; P<0.001), pancreatic surgical procedures (OR 2.4, 95% CI 1.6, 3.7; P<0.001), and mechanical ventilation (OR 21.2, 95% CI 16.5, 27.3; P<0.001) were associated with increased mortality. CONCLUSION: PN is associated with increased mortality, HACs, PSIs and healthcare resource utilization in patients hospitalized with AP. The use of PN needs to carefully weighed against perceived benefits in management of severe AP.
(10.9%) succumbed to the illness. Mean plasma OPN levels at admission were 14.84 ±11.08, CRP were 58.63±9.57mg/ml and NT-Pro-BNP were 4.63±2.72ng/ml. The mean levels of OPN, NT-Pro-BNP and CRP amongst survivors and non-survivors were 13.56±9.57 and 24.24±16.24 ng/ml (p=000), 4.5±2.8 and 5.0±1.3 ng/ml(p=.522) and 58.48±10 & 59.61±5.62mg/l (P=.624) respectively. The mean levels of OPN, NT-Pro-BNP and CRP amongst those needing percutaneous drainage vis-a-vis those not needing it were 20.27 ± 11.15 and 13.97 ± 11.07 ng/ml (p=0.015), 5.55 ± 3.26 and 4.47 ± 2.62 ng/ml (p=0.104), 59 ± 8.2 and 59 ± 8.78 mg/L (p=0.964).The mean levels of OPN, NT-Pro-BNP and CRP amongst patients with POF vis-a-vis those without POF were 18.62 ± 11.75 and 9.21 ± 7.63 ng/mL (p=0.000), 5.01 ± 2.65 and 3.97± 2.8 ng/mL (P=0.026) and 59.68 ± 9.0 and 58.05 ± 7.8 mg/L (p=0.270). The area under the Receiver Operator Curve (AUROC) for predicting mortality was 0 .714, 0.620 and 0.597 for plasma OPN, NT-pro-BNP and CRP, respectively. The AUROC for predicting need for pigtail insertion was 0.677, 0.687 and 0.459 for plasma OPN, NT-pro-BNP and CRP, respectively. The AUROC for predicting POF was 0.745, 0.671 and 0.495 for OPN, NT-pro-BNP and CRP, respectively. Conclusion: Plasma osteopontin levels at admission predicts mortality in patients with AP better than admission NT-Pro-BNP and CRP levels.
Mo1423 Calcium Profile in Acute Pancreatitis and Outcome Prediction Using Serum Corrected Calcium (CCa) and Ionised Calcium Levels (iCa) in the Era of Revised atlanta Classification Puneet Chhabra, Ravi Sharma, Vishal Sharma, Naresh Sachdeva, Surinder S. Rana, Deepak K. Bhasin
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INTRODUCTION : Calcium has been a part of various scoring systems which predict severity in AP. Literature on calcium profile (Serum CCa, Ica, Vitamin D3, iPTH) in AP and prediction of outcome using Serum CCa and iCa is scarce. Aim :To study the calcium profile and prognostic significance of serum Cca and iCa levels In patients with AP. Methods :Retrospective analysis of prospectively recorded data of consecutive patients of AP presenting within 7 days of admission to the hospital was retrieved. Apart from routine investigations , serum Cca, iCa, Vit. D3, iPTH, BISAP, SIRS and APACHE II were analysed. Hypocalcemia was defined as Serum Cca <8 mg/dl. Persistent organ failure (POF), need for intervention and mortality were studied as outcome measures. RESULTS: Of 151 patients (mean age 38.45 ± 13.3 years, 80 males), 56 (37.08 %) had severe pancreatitis. Mean serum Cca, iCa, Vit. D3 and ipTH were 8.5 ±1.20 mg/dl, 0.74± 0.24 mmol/l, 8.2 ± 6.73 ng/ml and 96.8 ± 253.2 pg/ml respectively.Alcohol and Gall stone disease were the most common etiologies of AP. Necrotizing pancreatitis was seen in 58 (32%) of patients. Twenty four (16%) patients died. Hypocalcemia was present in 37 (24.5%) patients. Patients with severe pancreatitis had significantly low Vitamin D3, serum Cca and serum iCa as compared to patients with moderately severe and mild AP (P<0.05). iPTH levels were significantly higher in patients with severe pancreatitis as compared to patients with mild and moderately severe AP(P <0.0.5). AUROC for prediction of mortality in AP for iCa, Cca, BISAP, SIRS and APACHE II was 0.841, 0.842,0.822,0.742,0.840 respectively. The corresponding sensitivity and specificity for prediction of mortality (optimum value with the maximum sensitivity and specificity) as calculated through ROC for iCa, Cca, BISAP, SIRS and APACHE II are given in table 1.On multivariate analysis using binary logistic regression, only SIRS >2, BISAP >2 and Cca (P<0.05) assumed significance. For prediction ofseverity (POF), AUROC for iCa, Cca, BISAP, SIRS and APACHE II was 0.807, 0.721, 0.795, 0.743 and 0.806 respectively. The corresponding sensitivity and specificity for prediction of severity (optimum value with the maximum sensitivity and specificity) as calculated through ROC are given in table 2. CONCLUSION - Hypocalcemia predicts a poor outcome in acute pancreatitis. Serum corrected calcium and ionised calcium are better predictors of severity and mortality in acute pancreatitis as compared to APACHE II, SIRS and BISAP. Table 1 Sensitivity and Specificity of various predictors for mortality in AP
Elevated Levels of IL-6 and IL-8 Predict Development of Respiratory Failure in Patients With Acute Pancreatitis Jayanta Samanta, Sukhwinder Singh, Raghavendra Prasad, Narendra Dhaka, Sunil K. Arora, Ashutosh Nath Aggrawal, Vikas Gupta, Thakur D. Yadav, Saroj K. Sinha, Rakesh Kochhar Introduction: Acute lung injury (ALI) is the commonest organ failure in patients with acute pancreatitis(AP). It is a major cause of early mortality in such patients and cytokines play a major role in its pathophysiology. Aims & Methods: To study the predictive role of inflammatory cytokines in development of ALI in patients with AP. In this prospective study between July 2013 and December 2014 consecutive eligible patients of AP underwent complete demographic, clinical, biochemical and radiological evaluation. Severity classification was done using revised Atlanta classification and also systemic inflammatory response score (SIRS), Bedside Index of Severity of Acute Pancreatitis(BISAP), CT Severity Index(CTSI) and APACHE II scores were used. Serial arterial blood gas (ABG) analyses were done and ALI defined as per PaO2/FiO2 ratio. Serum levels of interleukin (IL)-6, IL-8, IL-10, IL-1b and TNFa were measured at baseline (day 1) for all patients and on day 3 in those who had ALI. Patients were divided into 2 groups: with and without ALI. ALI cohort further subdivided into persistent ALI (P-ALI) and transient ALI (T-ALI). A subgroup of ALI patients who developed ALI later during hospital stay was defined as "late onset" ALI (LO-ALI) to devise a predictive model for ALI using cytokine levels. Statistical analysis was done using SPSSv22.0 Results: Of the 107 patients (mean age of 38.4 yrs, 64.5% males, etiology: alcohol 36.4% gallstone disease 26.2% and others 51.4%), ALI developed in 51 (47.7%) of whom 40(78.4%) had ALI on admission while 11(21.6%) had LO-ALI. TALI was seen in 16(31.4%) while 35 (68.6%) had P-ALI. Patients with ALI had significantly higher IL 1b (p<0.0001), IL-6(p<0.0001), IL-8(P<0.001) and TNFa(P<0.0001) and lower IL10(p<0.0001) levels on day 1, when compared to non-ALI group. In the ALI group, day 3 levels of IL-1b (p=0.001), IL-6 (p=0.02), IL-8 (p=0.006) and TNF a(p=0.006) were significantly higher than day 1 levels. Significant rise on day 3 of only IL-1b (p=0.04) was observed in T-ALI group as compared to both IL-1b (p=0.001) and TNF a(p=0.02) in the P-ALI group. Day 1 levels of IL-6 and IL-8 had strong positive correlation with severity indices such as SIRS(p<0.001), BISAP(p<0.001) and CTSI(p<0.0001) as also with outcome measures such as need for intervention (p<0.0001), hospital stay(p<0.0001) and intensive care stay(p<0.0001). LO-ALI group had significantly higher levels of IL 6(p<0.0001), IL8(p<0.0001), TNFa(p<0.0001) and IL-1b(p<0.006). IL-6 at cut off levels of 84.85 pg/mL (AUC=0.94, sensitivity & specificity 91%) and IL-8 at cut off level of 112.5 pg/mL (AUC= 0.909, sensitivity 91% specificity 94.6%) predicted subsequent development of ALI. Conclusion: Rising levels of IL-1b and TNF a suggest development of persistent ALI. IL-6 and IL8 levels at admission can predict the future development of late onset ALI
Table 2 Sensitivity and Specificity of various predictors for severity in AP
Mo1422 Comparison of Plasma Osteopontin, Pro-Brain Natriuretic Peptide and CRP Levels at Admission for Prognostication in Acute Pancreatitis Ravi Sharma, Vishal Sharma, Puneet Chhabra, Deepak Gunjan, Satya Vati Rana, Rajesh Gupta, Surinder S. Rana, Deepak K. Bhasin Introduction: Plasma Osteopontin (OPN), N-terminal pro Brain natriuretic peptide (NTPro-BNP) and C-reactive protein (CRP) are markers of inflammation. Role of OPN and NTPro-BNP in acute pancreatitis (AP) has not been previously evaluated vis-a-vis CRP. Aim: To estimate the levels of plasma OPN, NT-Pro-BNP and CRP on admission in patients with AP and to evaluate and compare their role in predicting severity, complication and mortality in AP. Methods: Consecutive patients presenting with AP and admitted within 7 days of onset of symptoms were enrolled. The plasma OPN, CRP and NT-Pro-BNP levels were estimated in the plasma collected on the day of admission. These patients were followed till discharge or death. The association of plasma OPN,CRP and NT-Pro-BNP levels with severity, persistent organ failure(POF), mortality were analysed and their diagnostic utility were compared by receiver operator characteristics (ROC). Result: One hundred sixty five consecutive patients (101 males (61.2%) with mean age 39.77±12.84 years) were enrolled. The most common cause was alcohol (N=76, 46.06%) followed by gallstones (N=63, 38.2%). Acute fluid collections were noted in 126 (76.4%) patients and acute necrotizing pancreatitis in 105 (63.6%) patients. Persistent organ failure developed in 98 patients (59.39%). The mean CTSI was 6.08± 2.84. Thirty nine patients (23.6%) required intervention while 18
AGA Abstracts
Mo1424 Predictors of In-Hospital Mortality in Acute Pancreatitis David Mossad, Musleh Mustafa, Ronald J. Markert, Sangeeta Agrawal Introduction Acute pancreatitis presents with significant risk of morbidity and mortality. Multiple scoring systems have looked at several risk factors to predict the severity of acute pancreatitis. In this study, we evaluated the role of demographics, comorbidities, and health system characteristics on in-hospital mortality in acute pancreatitis patients. Methods We used ICD-9 diagnosis codes from the 2001-2010 National Hospital Discharge Survey to
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June 1, 2009 and December 31, 2013 were enrolled. Severe acute pancreatitis was diagnosed by the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008). This retrospective cohort study consists of two phases. First, the new scoring system was derived from the patients between 2009 and 2012. Multiple logistic regression analysis was used to identify possible predictors of the mortality. The model was chosen from variables selected by the stepwise subset procedure. The utility of this new scoring system, described with the area under the receiver-operating characteristic curve (AUC), was compared with the Atlanta classification using Delong's test. Secondly, we validated the new scoring system with patients in 2013. Results In the first phase, the mortality was 12.7% (112/882 patients). Four variables including age ‡70 years (+1), PaO2 £60 mmHg (room air) or mechanical ventilation (+1), ‘BUN ‡40 mg/dL (or Cr ‡2.0 mg/dL) or oliguria (daily urine output <400 mL even after adequate intravenous fluid resuscitation) (+1), and LDH ‡2 times upper limit of the normal range (+1) were left significant by stepwise multivariate analysis of ten variables which were used in the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008). Mortality increased with each additional point (Table 1). The AUC value of the new score was 0.79 (95%CI[0.74-0.83]), while that of the Atlanta classification was 0.80 (95%CI[0.76-0.84]) (p=0.64) (Table 2). In the second phase, the mortality was 12.7% (30/237 patients). Mortality increased with each additional point (Table 1).The AUC value of the new score was 0.79 (95%CI[0.70-0.85]), while that of the Atlanta classification was 0.80 (95%CI[0.74-0.87]) (p=0.53) (Table 2). Conclusions Our new severity scoring system of acute pancreatitis at admission was as effective as the Atlanta classification to predict mortality. Mortality of each score in both derivation and validation cohort
AUC values and 95%CI for predicting mortality in both derivation and validation cohort.
Mo1426 Prediction of Progression to Walled-Off Necrosis in Acute Necrotizing Pancreatitis With Pancreatic Perfusion CT Akira Yamamiya, Katsuya Kitamura, Yu Ishii, Tomohiro Nomoto, Tadashi Honma, Jiro Munechika, Shinya Ikeda, Takehiko Gokan, Hitoshi Yoshida Objective Acute necrotizing pancreatitis (ANP) has a high mortality. It is reported that pancreatic perfusion computerized tomography (CT) is possible to detect early ischemia with potential to progress to pancreatic necrosis in the patients of acute pancreatitis (AP). The aim of this study was to investigate whether measuring pancreatic blood flow velocity (Fv) value with pancreatic perfusion CT for the patients of ANP could detect pancreatic ischemic changes and predict the progression of walled-off necrosis (WON). Methods Between June 2013 and September 2015, twenty patients who underwent pancreatic perfusion CT for the patients diagnosed ANP with contrast enhanced CT at Showa University Hospital were included in this study. This study was approved by the Medical Ethics Committee at our hospital. We retrospectively divided into two groups; 14 patients with WON (A group) and 6 patients without WON (B group). We measured the Fv value ratio of pancreatic ischemia site and not ischemia site with pancreatic perfusion CT between less than 48 hours from the diagnosis of AP and two weeks later, and investigated whether we could predict the progression of WON. The diagnosis of AP was based on the 2008 revised diagnostic criteria of Japanese Ministry of Health, Labour and Welfare, and WON was diagnosed based on the 2012 revised Atlanta Classification. Continuous variables were expressed as the mean ± SD. Results There were no significant differences in age, sex, etiology, modified CT severity index score and mortality between the groups. APACHE-II score was 7.5±3.3 point and 3.2±3.4 point for A and B groups, respectively (P=0.026). The duration of administration of antibiotics in A group was significantly longer than that of B group (17.1±18.1 days vs 5.2±0.4 days for A and B groups, respectively; P=0.001). The hospital stay in A group was significantly longer than that of B group (38.2±28.4 days vs 14.8±0.4 days for A and B groups, respectively; P=0.004). The Fv value ratio of pancreatic ischemia site and not ischemia site less than 48 hours from the diagnosis of AP with pancreatic perfusion CT was 0.4±0.2 and 0.3±0.2 for A and B groups, respectively (P=0.711), however, the Fv value ratio of two weeks later in A group was significantly lower than that of B group (0.4±0.2 vs 0.7±0.1 for A and B groups, respectively; P=0.004). Conclusions The measurement of the Fv value ratio of pancreatic ischemia site and not ischemia site of two weeks later from the diagnosis of AP with pancreatic perfusion CT may be useful in a prediction of the progression of WON.
In-hospital Mortality of Acute Pancreatitis Patients in Different regions of U.S.
Mo1425 New Severity Scoring System of Acute Pancreatitis at Admission Could Predict Mortality As Well As the Atlanta Classification Masayasu Horibe, Mitsuhito Sasaki, Masamitsu Sanui, Eisuke Iwasaki, Hirotaka Sawano, Takashi Goto, Tsukasa Ikeura, Tsuyoshi Hamada, Takuya Oda, Hideto Yasuda, Wataru Shinomiya, Dai Miyazaki, Kaoru Hirose, Katsuya Kitamura, Nobutaka Chiba, Takanori Kanai, Kazunori Takeda, Toshihiko Mayumi Objective The Atlanta classification has been used for evaluation of severity of acute pancreatitis. However, the classification requires persistent organ failure lasting at least 48 hours. We herein created a new severity scoring system at admission and validated it. Methods All consecutive patients with severe acute pancreatitis who admitted at 44 institutions between
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AGA Abstracts
AGA Abstracts
identify cases of acute pancreatitis. Comparisons on demographics, number of comorbidities, hospital length of stay (LOS), and selected health system characteristics were made between those who died in-hospital and those discharged. SPSS was used for chi-square and t test analysis at alpha = 0.05. Results Among 27,259 cases of acute pancreatitis, 573 died inhospital and 26,686 were discharged. The mortality group was older (mean age of 64.5 vs 51.8, p<0.001) and had a longer LOS (12.0 vs 6.4 days, p<0.001). There was no difference in mortality between genders (2.2% of males vs 2.0% of females, p=0.10), but Asians had the highest mortality (4.4%). Patients with four or more comorbidities had a higher mortality rate (2.5%) compared to those with three or fewer comorbidities (0.1%) (p<0.001). Midwest U.S. had a lower death rate (1.6%) compared to the Northeast (2.5%), South (2.2%), and West (2.4%) (p=0.002). Mortality rate was lowest in hospitals with 6-99 beds (1.3%), compared to greater than 2% in all other hospital sizes (p<0.001). Hospital ownership, however, did not show any significant differences in mortality (2.0% proprietary, 2.4% government, 2.1% nonprofit or church, p=0.49). The mortality rate among hospital ownership types was similar: 2.0% proprietary, 2.4% government, 2.1% nonprofit or church. Among sources of payment, Medicare (3.6%) and Medicaid (2.0%) patients had the highest mortality rates. For source of admission, transfer from ambulatory surgery centers (5.9%), hospitals (5.3%), and skilled nursing/intermediate care facilities (4.9%) had the highest mortality rates. Type of admission (e.g., emergent, elective) did no impact mortality. Conclusions Age, race, LOS, comorbidity burden, region of the U.S., hospital size, source of payment, and source of admission were related to higher in-hospital mortality. The lower mortality rate in small hospitals may be due to patients with a high risk of mortality being transferred to larger hospitals more capable of managing critically ill patients.
hospitalized patients with AP, and (b) to identify factors that predict mortality, hospital associated complications (HAC) and patient safety indicators (PSI) in patients hospitalized for AP and receiving PN. METHODS: The Nationwide Inpatient Sample (2008-2012) was reviewed to determine all adult patients ( ‡18 years) with a principle diagnosis of AP. The primary clinical outcomes were mortality, HAC, and PSI, while the secondary resource outcomes included length of hospital stay and hospital charges. Univariate and multivariate comparisons in patients with and without the use of PN followed by subgroup analysis among patients receiving PN were performed. RESULTS: PN use was associated with 4.1% (37,476/893,567) of all AP admissions. Importantly, the use of PN in patients hospitalized with AP has significantly declined from 2008 to 2012 (4.5% vs. 3.4%; P<0.001). Multivariate analysis revealed that PN use was independently associated with mortality in AP (odds ratio (OR) 1.3; 95% confidence interval (CI) 1.08, 1.63; P<0.01), any HAC (OR 1.6; 95% CI 1.4, 1.8; P<0.001), and PSI (OR 3.6; 95% CI 3.3, 3.8; P<0.001). Further, PN was independently associated with prolonged length of hospital stay (by 6.9 days; 95% CI 6.6, 7.2; P<0.001), and greater hospital charges ($13,160; 95% CI $12,328, $13,992; P<0.001). Subgroup multivariate analysis among patients who received PN revealed that increasing age (OR 1.1; 95% CI 1.05, 1.07; P<0.001), acute kidney injury (OR 4.0, 95% CI 3.3, 4.8; P<0.001), respiratory failure (OR 3.1, 95% CI 2.4, 3.9; P<0.001), pancreatic surgical procedures (OR 2.4, 95% CI 1.6, 3.7; P<0.001), and mechanical ventilation (OR 21.2, 95% CI 16.5, 27.3; P<0.001) were associated with increased mortality. CONCLUSION: PN is associated with increased mortality, HACs, PSIs and healthcare resource utilization in patients hospitalized with AP. The use of PN needs to carefully weighed against perceived benefits in management of severe AP.
(10.9%) succumbed to the illness. Mean plasma OPN levels at admission were 14.84 ±11.08, CRP were 58.63±9.57mg/ml and NT-Pro-BNP were 4.63±2.72ng/ml. The mean levels of OPN, NT-Pro-BNP and CRP amongst survivors and non-survivors were 13.56±9.57 and 24.24±16.24 ng/ml (p=000), 4.5±2.8 and 5.0±1.3 ng/ml(p=.522) and 58.48±10 & 59.61±5.62mg/l (P=.624) respectively. The mean levels of OPN, NT-Pro-BNP and CRP amongst those needing percutaneous drainage vis-a-vis those not needing it were 20.27 ± 11.15 and 13.97 ± 11.07 ng/ml (p=0.015), 5.55 ± 3.26 and 4.47 ± 2.62 ng/ml (p=0.104), 59 ± 8.2 and 59 ± 8.78 mg/L (p=0.964).The mean levels of OPN, NT-Pro-BNP and CRP amongst patients with POF vis-a-vis those without POF were 18.62 ± 11.75 and 9.21 ± 7.63 ng/mL (p=0.000), 5.01 ± 2.65 and 3.97± 2.8 ng/mL (P=0.026) and 59.68 ± 9.0 and 58.05 ± 7.8 mg/L (p=0.270). The area under the Receiver Operator Curve (AUROC) for predicting mortality was 0 .714, 0.620 and 0.597 for plasma OPN, NT-pro-BNP and CRP, respectively. The AUROC for predicting need for pigtail insertion was 0.677, 0.687 and 0.459 for plasma OPN, NT-pro-BNP and CRP, respectively. The AUROC for predicting POF was 0.745, 0.671 and 0.495 for OPN, NT-pro-BNP and CRP, respectively. Conclusion: Plasma osteopontin levels at admission predicts mortality in patients with AP better than admission NT-Pro-BNP and CRP levels.
Mo1423 Calcium Profile in Acute Pancreatitis and Outcome Prediction Using Serum Corrected Calcium (CCa) and Ionised Calcium Levels (iCa) in the Era of Revised atlanta Classification Puneet Chhabra, Ravi Sharma, Vishal Sharma, Naresh Sachdeva, Surinder S. Rana, Deepak K. Bhasin
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INTRODUCTION : Calcium has been a part of various scoring systems which predict severity in AP. Literature on calcium profile (Serum CCa, Ica, Vitamin D3, iPTH) in AP and prediction of outcome using Serum CCa and iCa is scarce. Aim :To study the calcium profile and prognostic significance of serum Cca and iCa levels In patients with AP. Methods :Retrospective analysis of prospectively recorded data of consecutive patients of AP presenting within 7 days of admission to the hospital was retrieved. Apart from routine investigations , serum Cca, iCa, Vit. D3, iPTH, BISAP, SIRS and APACHE II were analysed. Hypocalcemia was defined as Serum Cca <8 mg/dl. Persistent organ failure (POF), need for intervention and mortality were studied as outcome measures. RESULTS: Of 151 patients (mean age 38.45 ± 13.3 years, 80 males), 56 (37.08 %) had severe pancreatitis. Mean serum Cca, iCa, Vit. D3 and ipTH were 8.5 ±1.20 mg/dl, 0.74± 0.24 mmol/l, 8.2 ± 6.73 ng/ml and 96.8 ± 253.2 pg/ml respectively.Alcohol and Gall stone disease were the most common etiologies of AP. Necrotizing pancreatitis was seen in 58 (32%) of patients. Twenty four (16%) patients died. Hypocalcemia was present in 37 (24.5%) patients. Patients with severe pancreatitis had significantly low Vitamin D3, serum Cca and serum iCa as compared to patients with moderately severe and mild AP (P<0.05). iPTH levels were significantly higher in patients with severe pancreatitis as compared to patients with mild and moderately severe AP(P <0.0.5). AUROC for prediction of mortality in AP for iCa, Cca, BISAP, SIRS and APACHE II was 0.841, 0.842,0.822,0.742,0.840 respectively. The corresponding sensitivity and specificity for prediction of mortality (optimum value with the maximum sensitivity and specificity) as calculated through ROC for iCa, Cca, BISAP, SIRS and APACHE II are given in table 1.On multivariate analysis using binary logistic regression, only SIRS >2, BISAP >2 and Cca (P<0.05) assumed significance. For prediction ofseverity (POF), AUROC for iCa, Cca, BISAP, SIRS and APACHE II was 0.807, 0.721, 0.795, 0.743 and 0.806 respectively. The corresponding sensitivity and specificity for prediction of severity (optimum value with the maximum sensitivity and specificity) as calculated through ROC are given in table 2. CONCLUSION - Hypocalcemia predicts a poor outcome in acute pancreatitis. Serum corrected calcium and ionised calcium are better predictors of severity and mortality in acute pancreatitis as compared to APACHE II, SIRS and BISAP. Table 1 Sensitivity and Specificity of various predictors for mortality in AP
Elevated Levels of IL-6 and IL-8 Predict Development of Respiratory Failure in Patients With Acute Pancreatitis Jayanta Samanta, Sukhwinder Singh, Raghavendra Prasad, Narendra Dhaka, Sunil K. Arora, Ashutosh Nath Aggrawal, Vikas Gupta, Thakur D. Yadav, Saroj K. Sinha, Rakesh Kochhar Introduction: Acute lung injury (ALI) is the commonest organ failure in patients with acute pancreatitis(AP). It is a major cause of early mortality in such patients and cytokines play a major role in its pathophysiology. Aims & Methods: To study the predictive role of inflammatory cytokines in development of ALI in patients with AP. In this prospective study between July 2013 and December 2014 consecutive eligible patients of AP underwent complete demographic, clinical, biochemical and radiological evaluation. Severity classification was done using revised Atlanta classification and also systemic inflammatory response score (SIRS), Bedside Index of Severity of Acute Pancreatitis(BISAP), CT Severity Index(CTSI) and APACHE II scores were used. Serial arterial blood gas (ABG) analyses were done and ALI defined as per PaO2/FiO2 ratio. Serum levels of interleukin (IL)-6, IL-8, IL-10, IL-1b and TNFa were measured at baseline (day 1) for all patients and on day 3 in those who had ALI. Patients were divided into 2 groups: with and without ALI. ALI cohort further subdivided into persistent ALI (P-ALI) and transient ALI (T-ALI). A subgroup of ALI patients who developed ALI later during hospital stay was defined as "late onset" ALI (LO-ALI) to devise a predictive model for ALI using cytokine levels. Statistical analysis was done using SPSSv22.0 Results: Of the 107 patients (mean age of 38.4 yrs, 64.5% males, etiology: alcohol 36.4% gallstone disease 26.2% and others 51.4%), ALI developed in 51 (47.7%) of whom 40(78.4%) had ALI on admission while 11(21.6%) had LO-ALI. TALI was seen in 16(31.4%) while 35 (68.6%) had P-ALI. Patients with ALI had significantly higher IL 1b (p<0.0001), IL-6(p<0.0001), IL-8(P<0.001) and TNFa(P<0.0001) and lower IL10(p<0.0001) levels on day 1, when compared to non-ALI group. In the ALI group, day 3 levels of IL-1b (p=0.001), IL-6 (p=0.02), IL-8 (p=0.006) and TNF a(p=0.006) were significantly higher than day 1 levels. Significant rise on day 3 of only IL-1b (p=0.04) was observed in T-ALI group as compared to both IL-1b (p=0.001) and TNF a(p=0.02) in the P-ALI group. Day 1 levels of IL-6 and IL-8 had strong positive correlation with severity indices such as SIRS(p<0.001), BISAP(p<0.001) and CTSI(p<0.0001) as also with outcome measures such as need for intervention (p<0.0001), hospital stay(p<0.0001) and intensive care stay(p<0.0001). LO-ALI group had significantly higher levels of IL 6(p<0.0001), IL8(p<0.0001), TNFa(p<0.0001) and IL-1b(p<0.006). IL-6 at cut off levels of 84.85 pg/mL (AUC=0.94, sensitivity & specificity 91%) and IL-8 at cut off level of 112.5 pg/mL (AUC= 0.909, sensitivity 91% specificity 94.6%) predicted subsequent development of ALI. Conclusion: Rising levels of IL-1b and TNF a suggest development of persistent ALI. IL-6 and IL8 levels at admission can predict the future development of late onset ALI
Table 2 Sensitivity and Specificity of various predictors for severity in AP
Mo1422 Comparison of Plasma Osteopontin, Pro-Brain Natriuretic Peptide and CRP Levels at Admission for Prognostication in Acute Pancreatitis Ravi Sharma, Vishal Sharma, Puneet Chhabra, Deepak Gunjan, Satya Vati Rana, Rajesh Gupta, Surinder S. Rana, Deepak K. Bhasin Introduction: Plasma Osteopontin (OPN), N-terminal pro Brain natriuretic peptide (NTPro-BNP) and C-reactive protein (CRP) are markers of inflammation. Role of OPN and NTPro-BNP in acute pancreatitis (AP) has not been previously evaluated vis-a-vis CRP. Aim: To estimate the levels of plasma OPN, NT-Pro-BNP and CRP on admission in patients with AP and to evaluate and compare their role in predicting severity, complication and mortality in AP. Methods: Consecutive patients presenting with AP and admitted within 7 days of onset of symptoms were enrolled. The plasma OPN, CRP and NT-Pro-BNP levels were estimated in the plasma collected on the day of admission. These patients were followed till discharge or death. The association of plasma OPN,CRP and NT-Pro-BNP levels with severity, persistent organ failure(POF), mortality were analysed and their diagnostic utility were compared by receiver operator characteristics (ROC). Result: One hundred sixty five consecutive patients (101 males (61.2%) with mean age 39.77±12.84 years) were enrolled. The most common cause was alcohol (N=76, 46.06%) followed by gallstones (N=63, 38.2%). Acute fluid collections were noted in 126 (76.4%) patients and acute necrotizing pancreatitis in 105 (63.6%) patients. Persistent organ failure developed in 98 patients (59.39%). The mean CTSI was 6.08± 2.84. Thirty nine patients (23.6%) required intervention while 18
AGA Abstracts
Mo1424 Predictors of In-Hospital Mortality in Acute Pancreatitis David Mossad, Musleh Mustafa, Ronald J. Markert, Sangeeta Agrawal Introduction Acute pancreatitis presents with significant risk of morbidity and mortality. Multiple scoring systems have looked at several risk factors to predict the severity of acute pancreatitis. In this study, we evaluated the role of demographics, comorbidities, and health system characteristics on in-hospital mortality in acute pancreatitis patients. Methods We used ICD-9 diagnosis codes from the 2001-2010 National Hospital Discharge Survey to
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June 1, 2009 and December 31, 2013 were enrolled. Severe acute pancreatitis was diagnosed by the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008). This retrospective cohort study consists of two phases. First, the new scoring system was derived from the patients between 2009 and 2012. Multiple logistic regression analysis was used to identify possible predictors of the mortality. The model was chosen from variables selected by the stepwise subset procedure. The utility of this new scoring system, described with the area under the receiver-operating characteristic curve (AUC), was compared with the Atlanta classification using Delong's test. Secondly, we validated the new scoring system with patients in 2013. Results In the first phase, the mortality was 12.7% (112/882 patients). Four variables including age ‡70 years (+1), PaO2 £60 mmHg (room air) or mechanical ventilation (+1), ‘BUN ‡40 mg/dL (or Cr ‡2.0 mg/dL) or oliguria (daily urine output <400 mL even after adequate intravenous fluid resuscitation) (+1), and LDH ‡2 times upper limit of the normal range (+1) were left significant by stepwise multivariate analysis of ten variables which were used in the criteria of the Japanese Ministry of Health, Labour and Welfare study group (2008). Mortality increased with each additional point (Table 1). The AUC value of the new score was 0.79 (95%CI[0.74-0.83]), while that of the Atlanta classification was 0.80 (95%CI[0.76-0.84]) (p=0.64) (Table 2). In the second phase, the mortality was 12.7% (30/237 patients). Mortality increased with each additional point (Table 1).The AUC value of the new score was 0.79 (95%CI[0.70-0.85]), while that of the Atlanta classification was 0.80 (95%CI[0.74-0.87]) (p=0.53) (Table 2). Conclusions Our new severity scoring system of acute pancreatitis at admission was as effective as the Atlanta classification to predict mortality. Mortality of each score in both derivation and validation cohort
AUC values and 95%CI for predicting mortality in both derivation and validation cohort.
Mo1426 Prediction of Progression to Walled-Off Necrosis in Acute Necrotizing Pancreatitis With Pancreatic Perfusion CT Akira Yamamiya, Katsuya Kitamura, Yu Ishii, Tomohiro Nomoto, Tadashi Honma, Jiro Munechika, Shinya Ikeda, Takehiko Gokan, Hitoshi Yoshida Objective Acute necrotizing pancreatitis (ANP) has a high mortality. It is reported that pancreatic perfusion computerized tomography (CT) is possible to detect early ischemia with potential to progress to pancreatic necrosis in the patients of acute pancreatitis (AP). The aim of this study was to investigate whether measuring pancreatic blood flow velocity (Fv) value with pancreatic perfusion CT for the patients of ANP could detect pancreatic ischemic changes and predict the progression of walled-off necrosis (WON). Methods Between June 2013 and September 2015, twenty patients who underwent pancreatic perfusion CT for the patients diagnosed ANP with contrast enhanced CT at Showa University Hospital were included in this study. This study was approved by the Medical Ethics Committee at our hospital. We retrospectively divided into two groups; 14 patients with WON (A group) and 6 patients without WON (B group). We measured the Fv value ratio of pancreatic ischemia site and not ischemia site with pancreatic perfusion CT between less than 48 hours from the diagnosis of AP and two weeks later, and investigated whether we could predict the progression of WON. The diagnosis of AP was based on the 2008 revised diagnostic criteria of Japanese Ministry of Health, Labour and Welfare, and WON was diagnosed based on the 2012 revised Atlanta Classification. Continuous variables were expressed as the mean ± SD. Results There were no significant differences in age, sex, etiology, modified CT severity index score and mortality between the groups. APACHE-II score was 7.5±3.3 point and 3.2±3.4 point for A and B groups, respectively (P=0.026). The duration of administration of antibiotics in A group was significantly longer than that of B group (17.1±18.1 days vs 5.2±0.4 days for A and B groups, respectively; P=0.001). The hospital stay in A group was significantly longer than that of B group (38.2±28.4 days vs 14.8±0.4 days for A and B groups, respectively; P=0.004). The Fv value ratio of pancreatic ischemia site and not ischemia site less than 48 hours from the diagnosis of AP with pancreatic perfusion CT was 0.4±0.2 and 0.3±0.2 for A and B groups, respectively (P=0.711), however, the Fv value ratio of two weeks later in A group was significantly lower than that of B group (0.4±0.2 vs 0.7±0.1 for A and B groups, respectively; P=0.004). Conclusions The measurement of the Fv value ratio of pancreatic ischemia site and not ischemia site of two weeks later from the diagnosis of AP with pancreatic perfusion CT may be useful in a prediction of the progression of WON.
In-hospital Mortality of Acute Pancreatitis Patients in Different regions of U.S.
Mo1425 New Severity Scoring System of Acute Pancreatitis at Admission Could Predict Mortality As Well As the Atlanta Classification Masayasu Horibe, Mitsuhito Sasaki, Masamitsu Sanui, Eisuke Iwasaki, Hirotaka Sawano, Takashi Goto, Tsukasa Ikeura, Tsuyoshi Hamada, Takuya Oda, Hideto Yasuda, Wataru Shinomiya, Dai Miyazaki, Kaoru Hirose, Katsuya Kitamura, Nobutaka Chiba, Takanori Kanai, Kazunori Takeda, Toshihiko Mayumi Objective The Atlanta classification has been used for evaluation of severity of acute pancreatitis. However, the classification requires persistent organ failure lasting at least 48 hours. We herein created a new severity scoring system at admission and validated it. Methods All consecutive patients with severe acute pancreatitis who admitted at 44 institutions between
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AGA Abstracts
AGA Abstracts
identify cases of acute pancreatitis. Comparisons on demographics, number of comorbidities, hospital length of stay (LOS), and selected health system characteristics were made between those who died in-hospital and those discharged. SPSS was used for chi-square and t test analysis at alpha = 0.05. Results Among 27,259 cases of acute pancreatitis, 573 died inhospital and 26,686 were discharged. The mortality group was older (mean age of 64.5 vs 51.8, p<0.001) and had a longer LOS (12.0 vs 6.4 days, p<0.001). There was no difference in mortality between genders (2.2% of males vs 2.0% of females, p=0.10), but Asians had the highest mortality (4.4%). Patients with four or more comorbidities had a higher mortality rate (2.5%) compared to those with three or fewer comorbidities (0.1%) (p<0.001). Midwest U.S. had a lower death rate (1.6%) compared to the Northeast (2.5%), South (2.2%), and West (2.4%) (p=0.002). Mortality rate was lowest in hospitals with 6-99 beds (1.3%), compared to greater than 2% in all other hospital sizes (p<0.001). Hospital ownership, however, did not show any significant differences in mortality (2.0% proprietary, 2.4% government, 2.1% nonprofit or church, p=0.49). The mortality rate among hospital ownership types was similar: 2.0% proprietary, 2.4% government, 2.1% nonprofit or church. Among sources of payment, Medicare (3.6%) and Medicaid (2.0%) patients had the highest mortality rates. For source of admission, transfer from ambulatory surgery centers (5.9%), hospitals (5.3%), and skilled nursing/intermediate care facilities (4.9%) had the highest mortality rates. Type of admission (e.g., emergent, elective) did no impact mortality. Conclusions Age, race, LOS, comorbidity burden, region of the U.S., hospital size, source of payment, and source of admission were related to higher in-hospital mortality. The lower mortality rate in small hospitals may be due to patients with a high risk of mortality being transferred to larger hospitals more capable of managing critically ill patients.