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S1368 Influence of Etiology on the Presence of Local Complications and Outcome of Acute Pancreatitis
AGA Abstracts
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Angiopoietin-2, a Regulator of Vascular Permeability in Inflammation, is Associated With Persistent Organ Failure in Patients With Acute Pancreatitis From the United States and Germany David C. Whitcomb, Venkata Muddana, Christopher J. Langmead, Frank D. Houghton, Annett Guenther, Patricia K. Eagon, Julia Mayerle, Ali Aghdassi, Frank U. Weiss, Janette Lamb, Gilles Clermont, Markus M. Lerch, Georgios I. Papachristou
Natural History of a Single Attack of Unexplained Pancreatitis C. Mel Wilcox, Toni Seay, Milind A. Phadnis, Shyam Varadarajulu, Mohamad A. Eloubeidi Background The appropriate evaluation for patients with a single attack of acute pancreatitis which remains unexplained after routine evaluation is unknown, because there is very little data for such patients on etiology and recurrence. Methods Patients referred to the investigators following a single attack of pancreatitis in which no cause was found after routine assessments and abdominal imaging (US, CT) were prospectively identified. All patients were evaluated by the investigators and imaging studies were reviewed to confirm the diagnosis of pancreatitis followed by endoscopic ultrasonography (EUS) to evaluate for pancreaticobiliary disorders. Surgery was recommended for patients in whom gallbladder disease or pancreatic mass lesions were identified. All other patients were followed expectantly by phone call and/or clinic visit every 3-6 months with ERCP and manometry recommended for recurrence. Results Over the 6.5 year study, 54 patients were identified (43 % female, 80% Caucasian, mean age 53 years, range 19 - 87). The median follow-up was 28 months (range 1 - 64 months). Following EUS, the most common diagnoses were: idiopathic 24 (45%), pancreas divisum 12 (22%), gallbladder microlithiasis 11 (20%), and chronic pancreatitis 5 (9%). Over the follow-up period, pancreatitis recurred in 8 patients (15%) of whom 4 underwent ERCP confirming the EUS diagnosis of pancreas divisum in 2, and diagnosing sphincter of Oddi dysfunction (SOD) in 2 others with presumed idiopathic disease. Conclusions The short-term natural history of patients with unexplained pancreatitis following EUS is favorable suggesting a limited utility for routine ERCP in such patients. EUS helped to identify microlithiasis. The majority of patients in whom no diagnosis is established after EUS will not have a recurrence.
Background: Patients with severe acute pancreatitis (AP) typically develop vascular leak syndrome, resulting in hemoconcentration, hypotension, pulmonary edema and renal insufficiency. Angiopoietin-1 (Ang-1) and 2 (Ang-2) are autocrine peptides that reduce or increase endothelial permeability, respectively. Aim: To determine whether Ang-1 and/or Ang-2 levels are predictive biomarkers of persistent (>48 hours) organ failure (OF) and prolonged hospital course. Methods: Banked serum from 46 patients enrolled at the University of Pittsburgh Medical Center (UPMC) and from 58 controls were analyzed for Ang-1 and Ang-2 levels. Separately, serum from 123 patients and 103 controls at Greifswald University (GU) were analyzed for Ang-2 levels. Angiopoietin levels were measured by ELISA. Results: 17 out of 46 UPMC patients (37%) and 14 out of 123 GU patients (13%) developed persistent OF and were classified as severe AP. Ang-2 was significantly higher on admission in patients who developed persistent OF compared with those who did not in the UPMC (3,698 vs. 1,001 pg/ml; p=0.001) and GU (4,945 vs. 2,631 pg/ml; p=0.0004) cohorts. Following data scaling, admission Ang-2 levels revealed an ROC of 0.81, sensitivity 90% and specificity 67% in predicting persistent OF. In addition, Ang-2 levels remained significantly higher in severe AP compared with mild AP patients until Day 7 (Days 2-4: p<0.005; Day 7: p<0.02). Ang-1 levels were not significantly different between mild and severe AP patients on admission in the UPMC cohort. Conclusions: Elevated serum Ang-2 levels on admission are associated with and may be a useful biomarker of predicting persistent OF and ongoing endothelial cell activation in AP.
S1368 Influence of Etiology on the Presence of Local Complications and Outcome of Acute Pancreatitis Isabel Pascual, Gemma Pacheco, Javier Lizarraga, Ramon Añon, Pilar Mas, Pedro Almela, Miguel Minguez, Adolfo Benages Background: It has been supposed and some studies suggest that there are differences with regard to the presence of local complications and outcome according to the etiological factor in acute pancreatitis (AP). Objective: To analyze the outcome and the frequency of local complications in AP patients according to etiology. Methods: All consecutive patients admitted with a first episode of AP between January 2000 and February 2008 were retrospectively studied. Those with chronic pancreatitis or recurrent episodes were excluded. All patients underwent an abdominal CT scan at 72-96 hours after admission (Balthazar Grading System). Analyzed data included etiology, age, local and/or systemic complications according to Atlanta classification, ICU admission, total time hospital admission and mortality. Severity was established according to the Atlanta classification. Results: We studied 791 patients. The etiology of the AP was biliary (ABP) in 557 patients (70.4 %), alcohol (AAP) in 105 (13.3 %) and miscellaneous (AMP) in 129 (idiopathic in 66 patients, due to hypertriglyceridemia in 15, post-ERCP in 13, and other causes in 35). AAP patients were younger(p<0.001)than ABP and AMP ones. The overall mortality rate was 3.3 % (26 deaths), 10 of them occurred during the first 48 h (these patients were excluded for the analysis of local complications). See table. AAP was associated (p<0.001) with Balthazar grades of severity (D-E). Local complications, necrosis and pseudocysts were more frequent in AAP (p< 0.05) than in ABP. There were no differences among the three etiologic groups respect to the presence of systemic complications (5.6 % in ABP, 5.8% in AAP and 7.6 % in AMP). Severe AP was more frequent (p < 0.05) in AAP (31.1%) than in ABP (19.9 %). There were no significant differences respect to mortality between ABP (2.5 %) and AAP (3.9 %); mortality in AMP patients was greater (6.1%), mainly due to post-ERCP and post-surgery AP. Admission in ICU was more frequent (p< 0.05) in AAP (12.6%) than in ABP (4.5 %) patients. Conclusions: Acute alcoholic pancreatitis patients have a higher incidence of necrosis and pseudocysts than other etiologies AP. There is no significant difference in mortality between alcoholic and biliary AP, perhaps conditioned to the younger age of AAP patients
Angiopoietin-2 values at admission by cohort and severity S1366 Prognostic Scores for Acute Pancreatitis Within 24 Hours of Admission: BISAP Versus APACHE-II Enrique de-Madaria, Gema Soler-Sala, Inmaculada Lopez-Font, Laura Gómez-Escolar, Laura Sempere, Cristina Sánchez-Fortún, Juan Martínez, Miguel Pérez-Mateo Most patients with acute pancreatitis (AP) show a favorable clinical course but approximately 20-25% develop local complications and/or organ failure with a high mortality rate. APACHEII is the most validated prognostic score for AP but it is complex and hardly used in the clinical practice. The easy-to-calculate Bedside Index for Severity in Acute Pancreatitis (BISAP) has been recently described and validated as a new prognostic system for AP. It consists of 5 easy-to-determine variables with one-point assignment each: blood urea nitrogen > 25 mg/dL, impaired mental status, systemic inflammatory response system, age > 60 years, and the presence of pleural effusion. Aim: to compare the ability of BISAP and APACHE II scores at hospital admission to predict mortality, persistent organ failure (POF) and pancreatic necrosis in patients with AP. Methods: analysis of prospectively acquired data from all the patients with AP admitted to our Unit from December 2007 to November 2009. Results: Among 231 episodes of AP, there were 7 (3%) deaths. The APACHE-II AUC for mortality, POF and pancreatic necrosis was 0.67, 0.61 and 0.55 versus BISAP AUC 0.7, 0.69 and 0.53 respectively. An APACHE II ≥8 points was associated with a 71.4% sensitivity, 58.5% specificity, 5.1% positive predictive value and 98.5% negative predictive value for mortality; its relative risk was 3.4 (95% CI 0,7-17,1) for mortality, 1.4 (95% CI 0.6-3.3) for POF and 1.2 (95% CI 0.6-2.3) for pancreatic necrosis. A BISAP score ≥3 points was associated with a 28.6% sensitivity, 91.5% specificity, 9.5% positive predictive value and a 97.6% negative predictive value for mortality; its relative risk was 4 (95% CI 0.8-19.4) for mortality, 2.9 (95% CI 1.03-7.9) for POF and 0.6 (95% CI 0.2-2.5) for pancreatic necrosis. Conclusions: A BISAP score ≥3 points was associated with higher specificity and positive predictive value than APACHE-II (≥8 points) for mortality, with a similar negative predictive value but had lower sensitivity. The BISAP system showed a higher AUC for mortality and persistent organ failure than the APACHE-II score.
AGA Abstracts
S1369 Platelets Activity in Acute Pancreatitis Joanna Osada, Milena I. Dabrowska, Urszula Wereszczynska-Siemiatkowska, Antoni Gabryelewicz, Andrzej Dabrowski Background: Acute pancreatitis (AP) is accompanied by hypercoagulation state that may affect the clinical course of AP. We evaluated the expression of platelets' glycoproteins GMP140 (CD62P), GpIIb (CD41), plasma concentration of beta-thromboglobulin (b-TG) as well as number of large platelets (L-PLT) and mean platelet component (MPC). Patients: 22 patients with AP (10 mild-AP [M-AP], 12 severe-AP [S-AP]; 10 women and 12 men, median age 50 years) were studied. The control group comprised of 20 healthy volunteers (9 women and 11 men, median age 42 years) without the history of recent inflammatory disease. Methods: PLT Gp/Receptors kit (Biocytex) allowed precise quantification of platelets' surface glycoproteins, at the resting state and after TRAP (Thrombin Receptor Activation Peptide) activation using flow cytometry (FACS Calibur; BD). For b-TG concentration ELISA
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Angiopoietin-2, a Regulator of Vascular Permeability in Inflammation, is Associated With Persistent Organ Failure in Patients With Acute Pancreatitis From the United States and Germany David C. Whitcomb, Venkata Muddana, Christopher J. Langmead, Frank D. Houghton, Annett Guenther, Patricia K. Eagon, Julia Mayerle, Ali Aghdassi, Frank U. Weiss, Janette Lamb, Gilles Clermont, Markus M. Lerch, Georgios I. Papachristou
Natural History of a Single Attack of Unexplained Pancreatitis C. Mel Wilcox, Toni Seay, Milind A. Phadnis, Shyam Varadarajulu, Mohamad A. Eloubeidi Background The appropriate evaluation for patients with a single attack of acute pancreatitis which remains unexplained after routine evaluation is unknown, because there is very little data for such patients on etiology and recurrence. Methods Patients referred to the investigators following a single attack of pancreatitis in which no cause was found after routine assessments and abdominal imaging (US, CT) were prospectively identified. All patients were evaluated by the investigators and imaging studies were reviewed to confirm the diagnosis of pancreatitis followed by endoscopic ultrasonography (EUS) to evaluate for pancreaticobiliary disorders. Surgery was recommended for patients in whom gallbladder disease or pancreatic mass lesions were identified. All other patients were followed expectantly by phone call and/or clinic visit every 3-6 months with ERCP and manometry recommended for recurrence. Results Over the 6.5 year study, 54 patients were identified (43 % female, 80% Caucasian, mean age 53 years, range 19 - 87). The median follow-up was 28 months (range 1 - 64 months). Following EUS, the most common diagnoses were: idiopathic 24 (45%), pancreas divisum 12 (22%), gallbladder microlithiasis 11 (20%), and chronic pancreatitis 5 (9%). Over the follow-up period, pancreatitis recurred in 8 patients (15%) of whom 4 underwent ERCP confirming the EUS diagnosis of pancreas divisum in 2, and diagnosing sphincter of Oddi dysfunction (SOD) in 2 others with presumed idiopathic disease. Conclusions The short-term natural history of patients with unexplained pancreatitis following EUS is favorable suggesting a limited utility for routine ERCP in such patients. EUS helped to identify microlithiasis. The majority of patients in whom no diagnosis is established after EUS will not have a recurrence.
Background: Patients with severe acute pancreatitis (AP) typically develop vascular leak syndrome, resulting in hemoconcentration, hypotension, pulmonary edema and renal insufficiency. Angiopoietin-1 (Ang-1) and 2 (Ang-2) are autocrine peptides that reduce or increase endothelial permeability, respectively. Aim: To determine whether Ang-1 and/or Ang-2 levels are predictive biomarkers of persistent (>48 hours) organ failure (OF) and prolonged hospital course. Methods: Banked serum from 46 patients enrolled at the University of Pittsburgh Medical Center (UPMC) and from 58 controls were analyzed for Ang-1 and Ang-2 levels. Separately, serum from 123 patients and 103 controls at Greifswald University (GU) were analyzed for Ang-2 levels. Angiopoietin levels were measured by ELISA. Results: 17 out of 46 UPMC patients (37%) and 14 out of 123 GU patients (13%) developed persistent OF and were classified as severe AP. Ang-2 was significantly higher on admission in patients who developed persistent OF compared with those who did not in the UPMC (3,698 vs. 1,001 pg/ml; p=0.001) and GU (4,945 vs. 2,631 pg/ml; p=0.0004) cohorts. Following data scaling, admission Ang-2 levels revealed an ROC of 0.81, sensitivity 90% and specificity 67% in predicting persistent OF. In addition, Ang-2 levels remained significantly higher in severe AP compared with mild AP patients until Day 7 (Days 2-4: p<0.005; Day 7: p<0.02). Ang-1 levels were not significantly different between mild and severe AP patients on admission in the UPMC cohort. Conclusions: Elevated serum Ang-2 levels on admission are associated with and may be a useful biomarker of predicting persistent OF and ongoing endothelial cell activation in AP.
S1368 Influence of Etiology on the Presence of Local Complications and Outcome of Acute Pancreatitis Isabel Pascual, Gemma Pacheco, Javier Lizarraga, Ramon Añon, Pilar Mas, Pedro Almela, Miguel Minguez, Adolfo Benages Background: It has been supposed and some studies suggest that there are differences with regard to the presence of local complications and outcome according to the etiological factor in acute pancreatitis (AP). Objective: To analyze the outcome and the frequency of local complications in AP patients according to etiology. Methods: All consecutive patients admitted with a first episode of AP between January 2000 and February 2008 were retrospectively studied. Those with chronic pancreatitis or recurrent episodes were excluded. All patients underwent an abdominal CT scan at 72-96 hours after admission (Balthazar Grading System). Analyzed data included etiology, age, local and/or systemic complications according to Atlanta classification, ICU admission, total time hospital admission and mortality. Severity was established according to the Atlanta classification. Results: We studied 791 patients. The etiology of the AP was biliary (ABP) in 557 patients (70.4 %), alcohol (AAP) in 105 (13.3 %) and miscellaneous (AMP) in 129 (idiopathic in 66 patients, due to hypertriglyceridemia in 15, post-ERCP in 13, and other causes in 35). AAP patients were younger(p<0.001)than ABP and AMP ones. The overall mortality rate was 3.3 % (26 deaths), 10 of them occurred during the first 48 h (these patients were excluded for the analysis of local complications). See table. AAP was associated (p<0.001) with Balthazar grades of severity (D-E). Local complications, necrosis and pseudocysts were more frequent in AAP (p< 0.05) than in ABP. There were no differences among the three etiologic groups respect to the presence of systemic complications (5.6 % in ABP, 5.8% in AAP and 7.6 % in AMP). Severe AP was more frequent (p < 0.05) in AAP (31.1%) than in ABP (19.9 %). There were no significant differences respect to mortality between ABP (2.5 %) and AAP (3.9 %); mortality in AMP patients was greater (6.1%), mainly due to post-ERCP and post-surgery AP. Admission in ICU was more frequent (p< 0.05) in AAP (12.6%) than in ABP (4.5 %) patients. Conclusions: Acute alcoholic pancreatitis patients have a higher incidence of necrosis and pseudocysts than other etiologies AP. There is no significant difference in mortality between alcoholic and biliary AP, perhaps conditioned to the younger age of AAP patients
Angiopoietin-2 values at admission by cohort and severity S1366 Prognostic Scores for Acute Pancreatitis Within 24 Hours of Admission: BISAP Versus APACHE-II Enrique de-Madaria, Gema Soler-Sala, Inmaculada Lopez-Font, Laura Gómez-Escolar, Laura Sempere, Cristina Sánchez-Fortún, Juan Martínez, Miguel Pérez-Mateo Most patients with acute pancreatitis (AP) show a favorable clinical course but approximately 20-25% develop local complications and/or organ failure with a high mortality rate. APACHEII is the most validated prognostic score for AP but it is complex and hardly used in the clinical practice. The easy-to-calculate Bedside Index for Severity in Acute Pancreatitis (BISAP) has been recently described and validated as a new prognostic system for AP. It consists of 5 easy-to-determine variables with one-point assignment each: blood urea nitrogen > 25 mg/dL, impaired mental status, systemic inflammatory response system, age > 60 years, and the presence of pleural effusion. Aim: to compare the ability of BISAP and APACHE II scores at hospital admission to predict mortality, persistent organ failure (POF) and pancreatic necrosis in patients with AP. Methods: analysis of prospectively acquired data from all the patients with AP admitted to our Unit from December 2007 to November 2009. Results: Among 231 episodes of AP, there were 7 (3%) deaths. The APACHE-II AUC for mortality, POF and pancreatic necrosis was 0.67, 0.61 and 0.55 versus BISAP AUC 0.7, 0.69 and 0.53 respectively. An APACHE II ≥8 points was associated with a 71.4% sensitivity, 58.5% specificity, 5.1% positive predictive value and 98.5% negative predictive value for mortality; its relative risk was 3.4 (95% CI 0,7-17,1) for mortality, 1.4 (95% CI 0.6-3.3) for POF and 1.2 (95% CI 0.6-2.3) for pancreatic necrosis. A BISAP score ≥3 points was associated with a 28.6% sensitivity, 91.5% specificity, 9.5% positive predictive value and a 97.6% negative predictive value for mortality; its relative risk was 4 (95% CI 0.8-19.4) for mortality, 2.9 (95% CI 1.03-7.9) for POF and 0.6 (95% CI 0.2-2.5) for pancreatic necrosis. Conclusions: A BISAP score ≥3 points was associated with higher specificity and positive predictive value than APACHE-II (≥8 points) for mortality, with a similar negative predictive value but had lower sensitivity. The BISAP system showed a higher AUC for mortality and persistent organ failure than the APACHE-II score.
AGA Abstracts
S1369 Platelets Activity in Acute Pancreatitis Joanna Osada, Milena I. Dabrowska, Urszula Wereszczynska-Siemiatkowska, Antoni Gabryelewicz, Andrzej Dabrowski Background: Acute pancreatitis (AP) is accompanied by hypercoagulation state that may affect the clinical course of AP. We evaluated the expression of platelets' glycoproteins GMP140 (CD62P), GpIIb (CD41), plasma concentration of beta-thromboglobulin (b-TG) as well as number of large platelets (L-PLT) and mean platelet component (MPC). Patients: 22 patients with AP (10 mild-AP [M-AP], 12 severe-AP [S-AP]; 10 women and 12 men, median age 50 years) were studied. The control group comprised of 20 healthy volunteers (9 women and 11 men, median age 42 years) without the history of recent inflammatory disease. Methods: PLT Gp/Receptors kit (Biocytex) allowed precise quantification of platelets' surface glycoproteins, at the resting state and after TRAP (Thrombin Receptor Activation Peptide) activation using flow cytometry (FACS Calibur; BD). For b-TG concentration ELISA
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