- Email: [email protected]
Acute Pancreatitis: Trends in Outcomes and the Role of Acute Kidney Injury in Mortality
AGA Abstracts
physical or mental wellness, respectively. All scores are presented using norm-based comparisons (mean±SD for the U.S. general population is 50±10). A difference of 3 points is considered clinically significant. Linear regression models were developed to measure the independent effect of RAP on physical and mental QOL, determinants of QOL in RAP, and differential effects of covariates on QOL in RAP vs. CP. Results: Compared to controls (51.0±9.4), patients with RAP (41.1±11.4) and CP (37.2±11.8) had significantly lower physical component scores (p<0.0001). Patients with CP had significantly lower physical component scores compared to those with RAP alone (p<0.0001). Similarly, mental component scores were significantly lower among RAP (44.6±11.5) and CP (42.8±12.2) subjects compared to controls (51.7±9.1, p<0.0001). Patients with CP had significantly lower mental component scores compared to those with RAP alone (p<0.0072). After controlling for potential covariates (e.g., age, sex, race, alcohol use, smoking, and comorbidities), RAP was found to cause a clinically significant reduction in the physical component (estimate -8.46, p<0.0001; R-squared 0.34) and mental component scores (estimate -6.45, p<0.0001); Rsquared 0.19). Among RAP patients, factors independently associated with lower physical and mental QOL were female sex, smoking status and disability, while current drinking, prior pancreatic surgery, and endocrine insufficiency affected only PCS scores. Conclusions: Even in the absence of overt CP and after controlling for multiple covariates, patients with RAP have a significant decrease in both physical and mental QOL, with the magnitude of reduction intermediate between controls and CP patients. These results underscore the importance of identifying interventions to attenuate RAP before the development of overt CP.
290 MULTIPLE GENE INTERACTION INCREASES THE RISK OF RECURRENT ACUTE PANCREATITIS IN PATIENTS WITH PANCREAS DIVISUM Rupjyoti Talukdar, Mohsin Aslam, Steffie Avanthi, VV Ravikanth, Harshal Shah, Zaheer Nabi, Sundeep Lakhtakia, Manu Tandan, G. V. Rao, Duvur N. Reddy Background: Pancreas divisum (PD) as a cause of recurrent acute (RAP) and chronic pancreatitis (CP) is controversial. Benefit of minor papilla sphincterotomy for PD in patients with idiopathic RAP(IRAP) & CP(ICP) is debated. Earlier studies reported higher frequency of SPINK1, PRSS1 & CFTR variants with IRAP & ICP in presence of PD. In this study we report the effect of single nucleotide polymorphisms (SNPs) and gene-gene interaction on the risk of RAP & CP in presence of PD. Methods: We enrolled 687 individuals (167 IRAP, 276 ICP & 244 matched controls) from May 2015-Sept 2016. We initially evaluated association of the following SNPs with IRAP/ICP: SPINK1(rs17107315), PRSS1(rs111033566]), PRSS1(rs111033565), PRSS1(rs10273639), CTRC(rs140993290), CTRC(rs515726209), CTRC(rs497078), Cathepsin B (CTSB)(rs12338), Claudin2 (CLDN2)(rs7057398), CFTR (rs113993960), CFTR (rs113993959) & CFTR (rs75527207). Patients with IRAP & ICP were divided into those with or without PD (as confirmed by MRCP/ERCP). Demographic & disease characteristics were recorded. Associations between the significantly prevalent SNPs and IRAP/ICP in presence of PD were evaluated. Clinical data were analyzed using Mann-Whitney U & Chi Square test. Effect size of association of SNPs with IRAP/ICP was expressed as Odd's ratio (OR)(95%CI). Gene-gene interaction was assessed by transheterozygosity analyses. Bonferroni corrected two-tailed ‘p' value of <0.05 was considered statistically significant. Results: Following SNPs were significantly associated with IRAP/ICP: SPINK1 [OR(95%CI) 15.6(6.3-38.8); p<0.0001)], PRSS1(rs10273639) [OR(95%CI) 5.9(3.6-9.8); p<0.0001)]; CTRC(rs497078) [OR(95%CI) 6.2(3.1-12.6); p<0.0001], CTSB(rs12338) [OR(95%CI) 4.2(2.7-6.6); p<0.0001] and CLDN-2(rs7057398) [OR(95%CI) 7.1(4.6-11.1); p<0.0001]. 33(19.8%) & 82(29.7%) patients with IRAP & ICP respectively had PD. Demographic characteristics were similar, except for family history, which was higher among patients without PD [IRAP: 0(0%) v/s 18(15.5%); p=0.02 & ICP 5(2.2) v/s 42(18.4); p=0.003]. Mean(SD) pancreatic duct diameter (mm) was significantly higher in the presence of PD in patients with both IRAP [1.6(0.6) v/s 1.3(0.6); p=0.002)] and ICP [5.2(2.8) v/s 4.5(3.8); p=0.02]. PRSS1(rs10273639) & CTSB(rs12338) SNPs were significantly associated with IRAP [OR(95%CI) 3.9(1.2-12.7); p=0.02 & 3.5(1.2-10.4); p= 0.02 respectively] among patients with PD. No association was observed with ICP. On transheterozygosity analysis, combination of PRSS1(rs10273639) & CTSB(rs12338) SNPs increased the risk of RAP in presence of PD by 5-folds [OR(95%CI) 5.0(1.2-20.1); p=0.02]. Conclusion: We identified a subgroup of patients with SNPs in PRSS1 & CTSB genes who are at increased risk of developing RAP in presence of PD (Fig.1). These patients may benefit from minor papilla sphincterotomy. This needs testing in a randomized controlled setting.
289 COMPARISON OF NORMAL SALINE VERSUS LACTATED RINGER'S SOLUTION FOR FLUID RESUSCITATION IN PATIENTS WITH ACUTE PANCREATITIS , A RANDOMIZED CONTROLLED TRIAL Sararak Choosakul, Kamin Harinwan, Sakkarin Chirapongsathorn, Chaipichit Puttapitakpong Introduction: Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis. The previous open-label randomized controlled trial suggested that fluid resuscitation with Lactated Ringer's solution (LRS) may be associated to reduce inflammation compared with Normal Saline solution (NSS). Methods: We performed a randomized controlled trial in patients with acute pancreatitis. The patients were randomized into two groups. Each group received Normal Saline or Lactated Ringer's solution with goal-directed fluid resuscitation protocol. Mortality, presence of local complication, SIRs at 24 and 48 hours, ESR, CRP and procalcitonin were measured. Results: Forty-seven patients were included. Twenty-four patients (51%) received NSS, and 23 (49%) received LRS. Mortality was not different between NSS 1 (4.2%) and LRS 0 (0%), p=1. There was significant reduction in SIRs after 24 hours among subjects resuscitated with LRS (26.1%) compared with NSS (4.2%), p=0.02, but SIRs reduction at 48 hours was not different between two groups, (26.1% in LRS, 33.4% in NSS), p=1. CRP, ESR and procalcitonin increased at 24 hours and 48 hours after admission with no difference between two groups too. Local complications present 21.7% in LRS and 29.2% in NSS, p=0.74. Median Length of hospital stay were 6 days in LRS and 5.5 days in NSS, p=0.915. Conclusions: Lactated Ringer's solution, when compared to Normal Saline, is associated only with decreased SIRs at 24 hours, but the mortality rate was not different between LRS and NSS. Research outcome
291 ACUTE PANCREATITIS: TRENDS IN OUTCOMES AND THE ROLE OF ACUTE KIDNEY INJURY IN MORTALITY Kalpit H. Devani, Paris Charilaou, Febin John, Mark Young, Chakradhar M. Reddy Background: Acute pancreatitis (AP) is the one of the most common causes of Gastrointestinal disease (GI) related hospitalization in the USA with substantial mortality and morbidity from secondary organ damage. Aim: To evaluate national trends in hospitalization and mortality amongst patient with AP and determine predictors of AKI and mortality. Method: We queried the Nationwide Inpatient Sample (NIS) database from 2003 to 2012 to identify patients diagnosed with AP using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. After excluding patients with missing information on age, gender and inpatient mortality, we used ICD-9-CM codes to identify systemic inflammatory response syndrome (SIRS), sepsis, septic shock, AKI and acute respiratory failure (ARF). We specifically analyzed inpatient mortality, length of stay (LOS) and total hospital charges. Trends were tested with survey-weighted regressions. Predictors of AKI and inpatient mortality were analyzed by multivariate logistic regression. Additionally, AKI vs non-AKI groups were propensity-matched and regressed against inpatient mortality. Results: A total of 3,466,493 (1.13% of all discharges) patients with AP as top three discharge diagnosis were identified, of which 7.9% had AKI. Mean age of the study population was 53 years; 50.4% were females and 65.3% whites. Mean LOS was 5.6 days and mean cost of hospitalization was $12,087, while amongst the patients with AKI mean LOS was 10.3 days and mean cost was $25,923. Hospitalization rate of AP has increased from 1.02% in 2003 to 1.26% in 2012 (p<0.001) and proportion of AP with AKI patients has also increased by 7.6%, p<0.001 (Fig. 1). Aggregate cost of hospitalization for AP has increased from $3.52 billion to $4.03 billion while mean cost of individual hospitalization and LOS has decreased over the study period. Despite increasing hospitalization rate and AKI prevalence, mortality rate decreased over the study period. Overall mortality was 1.4% vs. 8.8% in the AKI subgroup. Age, male gender, rural and non-teaching hospital, comorbidities and complications especially septic shock (OR: 47.46, p<0.001), AKI (OR: 5.04, p<0.001 and propensitymatched OR: 2.05, p<0.001) and ARF (OR: 27.71, p<0.001) were associated with higher mortality (Fig.2). Conclusion: Mortality in patients with AP has decreased significantly
AGA Abstracts
S-72
Comparison of Post-ERCP Pancreatitis Rates in all Patients undergoing ERCP and Patients with PSC.
293 A RANDOMIZED CONTROLLED TRIAL OF PROTON PUMP INHIBITORS IN THE TREATMENT OF ACUTE PANCREATITIS PATIENTS: THE BENEFITS AND HARMS Xiao Ma, Ling Liu, Huan Tong, Shihang Tang, Cheng Ye, Yang Tai, Chengwei Tang Background: Proton pump inhibitors (PPIs) are widely used in acute pancreatitis (AP) for its indirect inhibition of pancreatic secretion and the prevention of stress ulcer. Besides, previous studies have shown that anti-acid therapy with PPIs might increase the incidence of small intestinal bacteria overgrowth (SIBO), which has negative effect on the prognosis of acute pancreatitis. However, there is limited evidence for the anti-acid therapy in AP. Objective: This prospective randomized study was designed to evaluate the association between the use of PPIs and SIBO incidence in patients with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), and the anti-acid effect of PPIs was also investigated. Methods: 50 patients meeting the inclusion criteria were enrolled in this study from 2015 October to 2016 October (MSAP: n=8; SAP: n=42). Patients were randomly assigned into two groups, the PPIs group (n=26, conventional treatment plus esomeprazole 40 mg/day intravenously) and the non-PPIs (n=24) group, conventional treatment without PPIs). Duodenal aspirates for SIBO, gastric pH and upper gastrointestinal manifestation were obtained by endoscopy on 7th day of hospitalization. Duodenal aspirates were taken to microbiology lab for aerobic and anaerobic culture, and bacterial growth >105 CFU/mL was considered to be the evidence of SIBO. In addition, the fecal occult blood was analyzed. Results: The baseline characteristics of the PPIs group and the non-PPIs group were comparable. The gastric pH was remarkably higher in the PPIs group, comparing to the Non-PPIs group (4.51±2.21 vs.2.74±1.00, P<0.001). Both the SIBO incidence of the aerobic bacteria and the anaerobic culture were significantly increased in the PPIs group (aerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 25%, P=0.005; anaerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 20.8%, P=0.002). There were no significant differences of the peptic ulcer incidence and fecal occult blood positivity between two groups (peptic ulcer: PPIs vs. non-PPIs 3.7% vs. 11.5% P=0.351; positive fecal occult blood: PPIs vs. non-PPIs 40.7% vs. 26.9% P=0.387). Besides, the fungal esophagitis was observed only in the PPIs group (PPIs vs. non-PPIs: 18.5% vs.0, P=0.028). Conclusions: PPIs cannot effectively decrease the occurrence of peptic ulcer and gastrointestinal hemorrhage in patients with MSAP and SAP. Furthermore, PPIs is associated with more SIBO and fungal esophagitis in these patients, and these sideeffects should be highly concerned.
Trends in hospitalization, inpatient mortality, lenght of stay and cost of hospitalization.
Multivariate logistic regression analysis for predictors of mortality and AKI.
292 PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS UNDERGOING ERCP ARE AT INCREASED RISK FOR PANCREATITIS: RECTAL INDOMETHACIN SIGNIFICANTLY REDUCES THE RISK Nikhil Thiruvengadam, Kimberly A. Forde, Vinay Chandrasekhara, Michael L. Kochman
294 THE EFFECT OF NATIONWIDE COLORECTAL CANCER SCREENING ON COLORECTAL CANCER INCIDENCE AND MORTALITY: A 30-YEAR CHRONOLOGICAL STUDY Yi-Chia Lee, ChenYang Hsu, Tsung-Hsien Chiang, Chu-kuang Chou, Han-Mo Chiu, Ming-Shiang Wu
Background ERCP is utilized in primary sclerosing cholangitis (PSC) patients with strictures and for evaluation of cholangiocarcinoma. Adverse events occur; however the risk of postERCP pancreatitis (PEP) has not been well defined. The benefit of PEP prophylaxis with rectal indomethacin is unclear in this population. The objective of this study was to determine the risk of PEP in PSC patients and the effect of rectal indomethacin on rate and severity of PEP. Methods We conducted a retrospective cohort study in 4545 ERCP patients, 200 with PSC, at the Hospital of the University of Pennsylvania between January 1, 2008 and December 31, 2015. After June 2012, 100 mg rectal indomethacin was routinely administered. Incidence of PEP, determined by the Cotton criteria, was the primary outcome and development of moderate to severe PEP was the secondary outcome. All patients were contacted within 48-72 hours of their procedure. Comparison of baseline characteristics and multivariable logistic regression modeling, with adjustment for confounders, was used to determine the risk of PEP in PSC patients and the association between indomethacin and the primary and secondary outcomes. Results Of the 200 patients with PSC, 13 (6.5%) developed PEP. The 92 patients who received indomethacin and 108 who were unexposed were significantly different with respect to age, common bile duct (CBD) brushing and type of anesthesia administered. 1.08% and 11.01% of PSC patients in the indomethacin exposed and unexposed cohorts, respectively, developed PEP. (Figure 1) In PSC patients who had a sphincterotomy performed during prior ERCP, 10% in the unexposed cohort developed PEP. After adjustment for other important risk factors, PSC was independently associated with PEP (OR 2.71, 95% CI 1.37 - 5.40, p<0.001) in the larger cohort. After adjustment for CBD brushing, dilatation and type of sedation administered, indomethacin significantly reduced the risk of PEP (OR 0.10, 95% CI 0.02 - 0.78, p<0.001) in PSC patients. For the secondary outcome, no patients in the indomethacin group developed moderate to severe PEP (0% vs. 8%, p=0.002). Discussion: In this retrospective cohort study, we demonstrated: 1. Patients with PSC and particularly those with a prior history sphincterotomy have a high rate of post-ERCP pancreatitis. 2. Rectal indomethacin significantly decreased the rates of PEP and moderate to severe pancreatitis. 3. These data suggest that PSC patients may have an elevated risk for PEP independent of sphincterotomy performed during prior ERCP, which may not reduce the risk during subsequent ERCP. 4. PSC patients may benefit from routine usage of rectal indomethacin following ERCP.
Objective: To evaluate the impact of Nationwide Colorectal Cancer Screening (NCCS) on the incidence and mortality of colorectal cancer (CRC) in Taiwan. Methods: Data on numbers of incident CRC and death from CRC were retrieved from National Cancer Registry from 1984 to 2013. Among 335 million person-years of follow-up (aged 30 years or more), 204,362 incident CRCs and 80,771 CRC-related deaths were observed. We separated the observation time into three periods (1984-1993, 1994-2003, and 2004-2013) to respectively indicate the implementation of a nationwide health insurance coverage (starting 1994) and NCCS (starting 2004). Because only subjects aged 50-69 years were eligible for NCCS with biennial fecal immunochemical testing, we separated population into three age groups (3049, 50-69, and 70-84 years). We applied the Poisson regression model to investigate the effect of NCCS on the time trends of CRC incidence and mortality, adjusting for the age and sex. The results were expressed with the relative risk (RR) and 95% CI. Results: The mean incidence rates for the periods of 1984-1993, 1994-2003, and 2004-2013 were 30.63, 55.57, and 84.36/100,000 person-years, respectively, and the corresponding mortality rates were 16.77, 24.32, and 28.47/100,000 person-years, indicating increasing trends throughout the study period. Male gender had a 32.1% increased risk for CRC and a 38.6% increased risk for CRC death, compared with those of female. In multivariate analyses, the period effect was statistically significant on both the incidence and mortality while the interactions between period and age and between period and sex were statistically significant. Using 1984-1993 as the baseline comparator, stratified analyses showed that the RRs (95% CIs) of CRC incidence during the period of 1994-2003 were 1.56 (1.51-1.62), 1.71 (1.68-1.74), and 2.01 (1.95-2.06), respectively, for the age groups of 30-49, 50-69, and 70-84; the corresponding figures for the period of 2004-2013 were 2.27 (2.20-2.35), 2.21 (2.17-2.25), and 2.81 (2.74-2.88). Regarding mortality, the respective RRs were 1.24 (1.18-1.32), 1.41 (1.37-1.44), and 1.51 (1.45-1.57) for 1994-2003, and 1.43 (1.36-1.51), 1.30 (1.27-1.33), and 1.64 (1.57-1.70) for 2004-2013. Only in the age group of 50-69, a significantly reduced mortality of 7.4% (1 minus 1.30/1.41, 95% CI: 5.5-9.3%) was noted during 2004-2013 as
S-73
AGA Abstracts
AGA Abstracts
during the study period, in spite of increasing hospitalizations and AKI rate. AP continues to be a significant economic burden to healthcare. Respiratory failure and septic shock are strongest predictors of AKI and inpatient mortality. AKI is independently associated with higher mortality and prolonged LOS with increasing hospitalization costs.
physical or mental wellness, respectively. All scores are presented using norm-based comparisons (mean±SD for the U.S. general population is 50±10). A difference of 3 points is considered clinically significant. Linear regression models were developed to measure the independent effect of RAP on physical and mental QOL, determinants of QOL in RAP, and differential effects of covariates on QOL in RAP vs. CP. Results: Compared to controls (51.0±9.4), patients with RAP (41.1±11.4) and CP (37.2±11.8) had significantly lower physical component scores (p<0.0001). Patients with CP had significantly lower physical component scores compared to those with RAP alone (p<0.0001). Similarly, mental component scores were significantly lower among RAP (44.6±11.5) and CP (42.8±12.2) subjects compared to controls (51.7±9.1, p<0.0001). Patients with CP had significantly lower mental component scores compared to those with RAP alone (p<0.0072). After controlling for potential covariates (e.g., age, sex, race, alcohol use, smoking, and comorbidities), RAP was found to cause a clinically significant reduction in the physical component (estimate -8.46, p<0.0001; R-squared 0.34) and mental component scores (estimate -6.45, p<0.0001); Rsquared 0.19). Among RAP patients, factors independently associated with lower physical and mental QOL were female sex, smoking status and disability, while current drinking, prior pancreatic surgery, and endocrine insufficiency affected only PCS scores. Conclusions: Even in the absence of overt CP and after controlling for multiple covariates, patients with RAP have a significant decrease in both physical and mental QOL, with the magnitude of reduction intermediate between controls and CP patients. These results underscore the importance of identifying interventions to attenuate RAP before the development of overt CP.
290 MULTIPLE GENE INTERACTION INCREASES THE RISK OF RECURRENT ACUTE PANCREATITIS IN PATIENTS WITH PANCREAS DIVISUM Rupjyoti Talukdar, Mohsin Aslam, Steffie Avanthi, VV Ravikanth, Harshal Shah, Zaheer Nabi, Sundeep Lakhtakia, Manu Tandan, G. V. Rao, Duvur N. Reddy Background: Pancreas divisum (PD) as a cause of recurrent acute (RAP) and chronic pancreatitis (CP) is controversial. Benefit of minor papilla sphincterotomy for PD in patients with idiopathic RAP(IRAP) & CP(ICP) is debated. Earlier studies reported higher frequency of SPINK1, PRSS1 & CFTR variants with IRAP & ICP in presence of PD. In this study we report the effect of single nucleotide polymorphisms (SNPs) and gene-gene interaction on the risk of RAP & CP in presence of PD. Methods: We enrolled 687 individuals (167 IRAP, 276 ICP & 244 matched controls) from May 2015-Sept 2016. We initially evaluated association of the following SNPs with IRAP/ICP: SPINK1(rs17107315), PRSS1(rs111033566]), PRSS1(rs111033565), PRSS1(rs10273639), CTRC(rs140993290), CTRC(rs515726209), CTRC(rs497078), Cathepsin B (CTSB)(rs12338), Claudin2 (CLDN2)(rs7057398), CFTR (rs113993960), CFTR (rs113993959) & CFTR (rs75527207). Patients with IRAP & ICP were divided into those with or without PD (as confirmed by MRCP/ERCP). Demographic & disease characteristics were recorded. Associations between the significantly prevalent SNPs and IRAP/ICP in presence of PD were evaluated. Clinical data were analyzed using Mann-Whitney U & Chi Square test. Effect size of association of SNPs with IRAP/ICP was expressed as Odd's ratio (OR)(95%CI). Gene-gene interaction was assessed by transheterozygosity analyses. Bonferroni corrected two-tailed ‘p' value of <0.05 was considered statistically significant. Results: Following SNPs were significantly associated with IRAP/ICP: SPINK1 [OR(95%CI) 15.6(6.3-38.8); p<0.0001)], PRSS1(rs10273639) [OR(95%CI) 5.9(3.6-9.8); p<0.0001)]; CTRC(rs497078) [OR(95%CI) 6.2(3.1-12.6); p<0.0001], CTSB(rs12338) [OR(95%CI) 4.2(2.7-6.6); p<0.0001] and CLDN-2(rs7057398) [OR(95%CI) 7.1(4.6-11.1); p<0.0001]. 33(19.8%) & 82(29.7%) patients with IRAP & ICP respectively had PD. Demographic characteristics were similar, except for family history, which was higher among patients without PD [IRAP: 0(0%) v/s 18(15.5%); p=0.02 & ICP 5(2.2) v/s 42(18.4); p=0.003]. Mean(SD) pancreatic duct diameter (mm) was significantly higher in the presence of PD in patients with both IRAP [1.6(0.6) v/s 1.3(0.6); p=0.002)] and ICP [5.2(2.8) v/s 4.5(3.8); p=0.02]. PRSS1(rs10273639) & CTSB(rs12338) SNPs were significantly associated with IRAP [OR(95%CI) 3.9(1.2-12.7); p=0.02 & 3.5(1.2-10.4); p= 0.02 respectively] among patients with PD. No association was observed with ICP. On transheterozygosity analysis, combination of PRSS1(rs10273639) & CTSB(rs12338) SNPs increased the risk of RAP in presence of PD by 5-folds [OR(95%CI) 5.0(1.2-20.1); p=0.02]. Conclusion: We identified a subgroup of patients with SNPs in PRSS1 & CTSB genes who are at increased risk of developing RAP in presence of PD (Fig.1). These patients may benefit from minor papilla sphincterotomy. This needs testing in a randomized controlled setting.
289 COMPARISON OF NORMAL SALINE VERSUS LACTATED RINGER'S SOLUTION FOR FLUID RESUSCITATION IN PATIENTS WITH ACUTE PANCREATITIS , A RANDOMIZED CONTROLLED TRIAL Sararak Choosakul, Kamin Harinwan, Sakkarin Chirapongsathorn, Chaipichit Puttapitakpong Introduction: Aggressive fluid resuscitation is recommended for initial management of acute pancreatitis. The previous open-label randomized controlled trial suggested that fluid resuscitation with Lactated Ringer's solution (LRS) may be associated to reduce inflammation compared with Normal Saline solution (NSS). Methods: We performed a randomized controlled trial in patients with acute pancreatitis. The patients were randomized into two groups. Each group received Normal Saline or Lactated Ringer's solution with goal-directed fluid resuscitation protocol. Mortality, presence of local complication, SIRs at 24 and 48 hours, ESR, CRP and procalcitonin were measured. Results: Forty-seven patients were included. Twenty-four patients (51%) received NSS, and 23 (49%) received LRS. Mortality was not different between NSS 1 (4.2%) and LRS 0 (0%), p=1. There was significant reduction in SIRs after 24 hours among subjects resuscitated with LRS (26.1%) compared with NSS (4.2%), p=0.02, but SIRs reduction at 48 hours was not different between two groups, (26.1% in LRS, 33.4% in NSS), p=1. CRP, ESR and procalcitonin increased at 24 hours and 48 hours after admission with no difference between two groups too. Local complications present 21.7% in LRS and 29.2% in NSS, p=0.74. Median Length of hospital stay were 6 days in LRS and 5.5 days in NSS, p=0.915. Conclusions: Lactated Ringer's solution, when compared to Normal Saline, is associated only with decreased SIRs at 24 hours, but the mortality rate was not different between LRS and NSS. Research outcome
291 ACUTE PANCREATITIS: TRENDS IN OUTCOMES AND THE ROLE OF ACUTE KIDNEY INJURY IN MORTALITY Kalpit H. Devani, Paris Charilaou, Febin John, Mark Young, Chakradhar M. Reddy Background: Acute pancreatitis (AP) is the one of the most common causes of Gastrointestinal disease (GI) related hospitalization in the USA with substantial mortality and morbidity from secondary organ damage. Aim: To evaluate national trends in hospitalization and mortality amongst patient with AP and determine predictors of AKI and mortality. Method: We queried the Nationwide Inpatient Sample (NIS) database from 2003 to 2012 to identify patients diagnosed with AP using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. After excluding patients with missing information on age, gender and inpatient mortality, we used ICD-9-CM codes to identify systemic inflammatory response syndrome (SIRS), sepsis, septic shock, AKI and acute respiratory failure (ARF). We specifically analyzed inpatient mortality, length of stay (LOS) and total hospital charges. Trends were tested with survey-weighted regressions. Predictors of AKI and inpatient mortality were analyzed by multivariate logistic regression. Additionally, AKI vs non-AKI groups were propensity-matched and regressed against inpatient mortality. Results: A total of 3,466,493 (1.13% of all discharges) patients with AP as top three discharge diagnosis were identified, of which 7.9% had AKI. Mean age of the study population was 53 years; 50.4% were females and 65.3% whites. Mean LOS was 5.6 days and mean cost of hospitalization was $12,087, while amongst the patients with AKI mean LOS was 10.3 days and mean cost was $25,923. Hospitalization rate of AP has increased from 1.02% in 2003 to 1.26% in 2012 (p<0.001) and proportion of AP with AKI patients has also increased by 7.6%, p<0.001 (Fig. 1). Aggregate cost of hospitalization for AP has increased from $3.52 billion to $4.03 billion while mean cost of individual hospitalization and LOS has decreased over the study period. Despite increasing hospitalization rate and AKI prevalence, mortality rate decreased over the study period. Overall mortality was 1.4% vs. 8.8% in the AKI subgroup. Age, male gender, rural and non-teaching hospital, comorbidities and complications especially septic shock (OR: 47.46, p<0.001), AKI (OR: 5.04, p<0.001 and propensitymatched OR: 2.05, p<0.001) and ARF (OR: 27.71, p<0.001) were associated with higher mortality (Fig.2). Conclusion: Mortality in patients with AP has decreased significantly
AGA Abstracts
S-72
Comparison of Post-ERCP Pancreatitis Rates in all Patients undergoing ERCP and Patients with PSC.
293 A RANDOMIZED CONTROLLED TRIAL OF PROTON PUMP INHIBITORS IN THE TREATMENT OF ACUTE PANCREATITIS PATIENTS: THE BENEFITS AND HARMS Xiao Ma, Ling Liu, Huan Tong, Shihang Tang, Cheng Ye, Yang Tai, Chengwei Tang Background: Proton pump inhibitors (PPIs) are widely used in acute pancreatitis (AP) for its indirect inhibition of pancreatic secretion and the prevention of stress ulcer. Besides, previous studies have shown that anti-acid therapy with PPIs might increase the incidence of small intestinal bacteria overgrowth (SIBO), which has negative effect on the prognosis of acute pancreatitis. However, there is limited evidence for the anti-acid therapy in AP. Objective: This prospective randomized study was designed to evaluate the association between the use of PPIs and SIBO incidence in patients with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), and the anti-acid effect of PPIs was also investigated. Methods: 50 patients meeting the inclusion criteria were enrolled in this study from 2015 October to 2016 October (MSAP: n=8; SAP: n=42). Patients were randomly assigned into two groups, the PPIs group (n=26, conventional treatment plus esomeprazole 40 mg/day intravenously) and the non-PPIs (n=24) group, conventional treatment without PPIs). Duodenal aspirates for SIBO, gastric pH and upper gastrointestinal manifestation were obtained by endoscopy on 7th day of hospitalization. Duodenal aspirates were taken to microbiology lab for aerobic and anaerobic culture, and bacterial growth >105 CFU/mL was considered to be the evidence of SIBO. In addition, the fecal occult blood was analyzed. Results: The baseline characteristics of the PPIs group and the non-PPIs group were comparable. The gastric pH was remarkably higher in the PPIs group, comparing to the Non-PPIs group (4.51±2.21 vs.2.74±1.00, P<0.001). Both the SIBO incidence of the aerobic bacteria and the anaerobic culture were significantly increased in the PPIs group (aerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 25%, P=0.005; anaerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 20.8%, P=0.002). There were no significant differences of the peptic ulcer incidence and fecal occult blood positivity between two groups (peptic ulcer: PPIs vs. non-PPIs 3.7% vs. 11.5% P=0.351; positive fecal occult blood: PPIs vs. non-PPIs 40.7% vs. 26.9% P=0.387). Besides, the fungal esophagitis was observed only in the PPIs group (PPIs vs. non-PPIs: 18.5% vs.0, P=0.028). Conclusions: PPIs cannot effectively decrease the occurrence of peptic ulcer and gastrointestinal hemorrhage in patients with MSAP and SAP. Furthermore, PPIs is associated with more SIBO and fungal esophagitis in these patients, and these sideeffects should be highly concerned.
Trends in hospitalization, inpatient mortality, lenght of stay and cost of hospitalization.
Multivariate logistic regression analysis for predictors of mortality and AKI.
292 PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS UNDERGOING ERCP ARE AT INCREASED RISK FOR PANCREATITIS: RECTAL INDOMETHACIN SIGNIFICANTLY REDUCES THE RISK Nikhil Thiruvengadam, Kimberly A. Forde, Vinay Chandrasekhara, Michael L. Kochman
294 THE EFFECT OF NATIONWIDE COLORECTAL CANCER SCREENING ON COLORECTAL CANCER INCIDENCE AND MORTALITY: A 30-YEAR CHRONOLOGICAL STUDY Yi-Chia Lee, ChenYang Hsu, Tsung-Hsien Chiang, Chu-kuang Chou, Han-Mo Chiu, Ming-Shiang Wu
Background ERCP is utilized in primary sclerosing cholangitis (PSC) patients with strictures and for evaluation of cholangiocarcinoma. Adverse events occur; however the risk of postERCP pancreatitis (PEP) has not been well defined. The benefit of PEP prophylaxis with rectal indomethacin is unclear in this population. The objective of this study was to determine the risk of PEP in PSC patients and the effect of rectal indomethacin on rate and severity of PEP. Methods We conducted a retrospective cohort study in 4545 ERCP patients, 200 with PSC, at the Hospital of the University of Pennsylvania between January 1, 2008 and December 31, 2015. After June 2012, 100 mg rectal indomethacin was routinely administered. Incidence of PEP, determined by the Cotton criteria, was the primary outcome and development of moderate to severe PEP was the secondary outcome. All patients were contacted within 48-72 hours of their procedure. Comparison of baseline characteristics and multivariable logistic regression modeling, with adjustment for confounders, was used to determine the risk of PEP in PSC patients and the association between indomethacin and the primary and secondary outcomes. Results Of the 200 patients with PSC, 13 (6.5%) developed PEP. The 92 patients who received indomethacin and 108 who were unexposed were significantly different with respect to age, common bile duct (CBD) brushing and type of anesthesia administered. 1.08% and 11.01% of PSC patients in the indomethacin exposed and unexposed cohorts, respectively, developed PEP. (Figure 1) In PSC patients who had a sphincterotomy performed during prior ERCP, 10% in the unexposed cohort developed PEP. After adjustment for other important risk factors, PSC was independently associated with PEP (OR 2.71, 95% CI 1.37 - 5.40, p<0.001) in the larger cohort. After adjustment for CBD brushing, dilatation and type of sedation administered, indomethacin significantly reduced the risk of PEP (OR 0.10, 95% CI 0.02 - 0.78, p<0.001) in PSC patients. For the secondary outcome, no patients in the indomethacin group developed moderate to severe PEP (0% vs. 8%, p=0.002). Discussion: In this retrospective cohort study, we demonstrated: 1. Patients with PSC and particularly those with a prior history sphincterotomy have a high rate of post-ERCP pancreatitis. 2. Rectal indomethacin significantly decreased the rates of PEP and moderate to severe pancreatitis. 3. These data suggest that PSC patients may have an elevated risk for PEP independent of sphincterotomy performed during prior ERCP, which may not reduce the risk during subsequent ERCP. 4. PSC patients may benefit from routine usage of rectal indomethacin following ERCP.
Objective: To evaluate the impact of Nationwide Colorectal Cancer Screening (NCCS) on the incidence and mortality of colorectal cancer (CRC) in Taiwan. Methods: Data on numbers of incident CRC and death from CRC were retrieved from National Cancer Registry from 1984 to 2013. Among 335 million person-years of follow-up (aged 30 years or more), 204,362 incident CRCs and 80,771 CRC-related deaths were observed. We separated the observation time into three periods (1984-1993, 1994-2003, and 2004-2013) to respectively indicate the implementation of a nationwide health insurance coverage (starting 1994) and NCCS (starting 2004). Because only subjects aged 50-69 years were eligible for NCCS with biennial fecal immunochemical testing, we separated population into three age groups (3049, 50-69, and 70-84 years). We applied the Poisson regression model to investigate the effect of NCCS on the time trends of CRC incidence and mortality, adjusting for the age and sex. The results were expressed with the relative risk (RR) and 95% CI. Results: The mean incidence rates for the periods of 1984-1993, 1994-2003, and 2004-2013 were 30.63, 55.57, and 84.36/100,000 person-years, respectively, and the corresponding mortality rates were 16.77, 24.32, and 28.47/100,000 person-years, indicating increasing trends throughout the study period. Male gender had a 32.1% increased risk for CRC and a 38.6% increased risk for CRC death, compared with those of female. In multivariate analyses, the period effect was statistically significant on both the incidence and mortality while the interactions between period and age and between period and sex were statistically significant. Using 1984-1993 as the baseline comparator, stratified analyses showed that the RRs (95% CIs) of CRC incidence during the period of 1994-2003 were 1.56 (1.51-1.62), 1.71 (1.68-1.74), and 2.01 (1.95-2.06), respectively, for the age groups of 30-49, 50-69, and 70-84; the corresponding figures for the period of 2004-2013 were 2.27 (2.20-2.35), 2.21 (2.17-2.25), and 2.81 (2.74-2.88). Regarding mortality, the respective RRs were 1.24 (1.18-1.32), 1.41 (1.37-1.44), and 1.51 (1.45-1.57) for 1994-2003, and 1.43 (1.36-1.51), 1.30 (1.27-1.33), and 1.64 (1.57-1.70) for 2004-2013. Only in the age group of 50-69, a significantly reduced mortality of 7.4% (1 minus 1.30/1.41, 95% CI: 5.5-9.3%) was noted during 2004-2013 as
S-73
AGA Abstracts
AGA Abstracts
during the study period, in spite of increasing hospitalizations and AKI rate. AP continues to be a significant economic burden to healthcare. Respiratory failure and septic shock are strongest predictors of AKI and inpatient mortality. AKI is independently associated with higher mortality and prolonged LOS with increasing hospitalization costs.