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Do endoscopic stigmata of stone migration predict the presence of common bile duct stones?
AJG – September, Suppl., 2002
Methods: Retrospective review from 1999 to 2001. Patient demographics and labs, length of stay, the indication for CT, ordering physician, and CT result were recorded. Severity of illness was assessed using the SAPS II score. Patients excluded with any of the following: pancreatitis not the principle reason for admission, patient discharged prior to obtaining CT, previous diagnosis of pancreatitis, lipase ⬍ 3 times the upper limit, and CT done without IV contrast. Variables associated with obtaining a CT were correlated using Fisher’s Exact test and two–sample t–test. Results: 108 patients met inclusion criteria. Of these, 58 underwent CT for evaluation of acute pancreatitis. There was no difference (all p⬎ 0.60) in markers of severity of illness in patients undergoing CT vs. no CT. There was a striking difference in length of stay (p ⫽ 0.0003), as patients not undergoing CT were discharged a mean of 3 days earlier. Most patients undergoing CT had alcoholic pancreatitis (p⫽0.047). There were a greater number of appropriate CT scans by the medical attending physicians and gastroenterology consultants in comparison with the resident housestaff and emergency room. In our 108 patients 75 had a prior ultrasound examination. Of those, 23 were reported as normal, and 13 of these 23 patients underwent CT. Conclusions: Physicians ordering CT scans for the evaluation of acute pancreatitis do so without regard to the severity of patient illness. These examinations prolong the length of stay dramatically such that costs from the test are substantial (charges⫽$4,700/CT at our institution). ER and medical resident personnel order inappropriate CT scans more often than consultants. An unremarkable ultrasound does not appear to greatly impact subsequent request for a CT scan. Continued refinement and dissemination of appropriate guidelines is needed.
183 DO ENDOSCOPIC STIGMATA OF STONE MIGRATION PREDICT THE PRESENCE OF COMMON BILE DUCT STONES? Vaman S. Jakribettuu, M.D., Girish Mishra, M.D., John H. Gilliam, M.D., Peter C. McNally, D.O. and Benoit C. Pineau, M.D.*. Section of Gastroenterology, University of Colorado Health Sciences Center, Denver, CO and Section of Gastroenterology, Wake Forest University Baptist Medical Center, Winston–Salem, NC. Purpose: Endoscopic stigmata of stone migration (ESSM) indicative of recent stone passage through the ampulla include: erythema and edema of the major papilla, patulous papillary os, presence of a choledocho– duodenal fistula, and/or sludge at the papillary os. No data are available on the accuracy of ESSM to predict the presence or absence of CBDS. The aim was to prospectively evaluate the prevalence and utility of ESSM to predict the presence of common bile duct stone (CBDS) Methods: 77 consecutive patients referred for management of suspected CBDS were included in the study. Patients underwent ERCP with careful inspection of the major papilla followed by selective cannulation and cholangiography. Balloon occlusion cholangiography was used as the gold standard for the detection of common bile duct stones. Results: Twenty–two (29%) of the 77 patients had ESSM on endoscopy (Table 1). ESSM were seen in similar proportion of patients presenting with gallstone pancreatitis (GP) and those with other presentations (30% Vs. 28%, p ⫽ NS). Twenty–9 (38%) of the 77 patients had CBDS. CBDS were more frequently found when ESSM were present but the difference was not statistically significant (ESSM present, 45% vs ESSM absent, 34%; p ⫽ NS). In the subgroup of patients with GP, CBDS were less common in patients with ESSM when compared to those without ESSM, but the difference was not statistically significant (ESSM present, 33% vs ESSM absent, 43%; p ⫽ NS). In the subgroup of 57 patients without GP, the presence of ESSM predicted the presence of CBDS (ESSM present, 50% vs ESSM absent, 31%; p ⬍ 0.05). Conclusions: Endoscopic stigmata of stone migration are present in 29% of patients with suspected CBDS. In the absence of gallstone pancreatitis, ESSM are associated with a higher probability of finding CBDS. Hence,
Abstracts
S61
ESSM do not exclude the presence of CBDS and should not alter the management plan in any patient subgroup. Table 1: CBDS and endoscopic stigmata of stone migration (ESSM) Condition (n)
CBDS present, ESSM present
CBDS present, ESSM absent
All patients (77) Pancreatitis (20) Other presentations (57)
10/22 (45%) 2/6 (33%) 8/16 (50%)
19/55 (34%) 6/14 (43%) 13/41 (31%)
P ⫽ NS P ⫽ NS P ⬍ 0.05
184 ACUTE PANCREATITIS FOLLOWING HEMATOPOIETIC STEM CELL TRANSPLANTATION IN CHILDREN Khalid Khan, M.B.Ch.B., Stella Davies, M.D., Rajaram Nagarajan, M.D. and Sally Weisdorf–Schindele, M.D.*. Pediatrics, University of Minnesota, Minneapolis, MN. Purpose: A decade ago acute pancreatitis was reported in 3.5% of children after bone marrow transplantation and associated with a poor outcome. Reports on adults have indicated that pancreatitis may be present in 30% of cases. We examined prevalence and risk factors for acute pancreatitis in the present day and how these have altered due to changes in transplant protocols. Methods: Data was reviewed on documented cases of pancreatitis in stem cell transplants performed from January 1996 –December 2001. The diagnosis was based on amylase and or lipase elevation (3⫻ normal) associated with abdominal pain in 7/8 and CT and laboratory findings in 1. Results: Eight cases of pancreatitis occurred in 445 transplants (1.8%). There were 4 males, age range 2–17 years (mean 10). Post transplant days ranged from 25–240 (mean 97.6). Symptoms in 7/8 lasted an average of 9.3 days (range 3–21), similarly enzyme elevation was present for 9.4 days (range 2–21). One female died 2 days after presentation from cardiac disease. Associated factors included a primary diagnosis of acute lymphoblastic leukemia (n ⫽ 2), acute myloid leukemia (n ⫽ 2), Fanconi’s anemia (n ⫽ 2), a matched unrelated marrow transplant (n ⫽ 5), drugs; methylprednisone (n ⫽ 5), cyclosporin A (n ⫽ 5) and bactrim (n ⫽ 6). One patient was on L–asparaginase and vincristine. Post transplant complications prior to pancreatitis included renal failure (n ⫽ 4), graft versus host disease (n ⫽ 4), cytomegalovirus infection (n ⫽ 3), hypertryglycedidemia (n ⫽ 3), and duodenal hematoma (n ⫽ 1). Radiology (CT and USS) was normal in all but 2 cases (a pseudocyst and peripancreatic inflammation). Apart from stopping oral intake and nasogastric suction treatment included octreotide (n ⫽ 1) and pancreatic enzymes (n ⫽ 1). All patients were on broad spectrum antibiotics and parenteral nutrition prior to pancreatitis. Complications occurred in 2 (exocrine pancreatic insufficiency and pseudocyst formation). No deaths occurred as a result of pancreatitis. Conclusions: The prevalence of acute pancreatitis after stem cell transplantation is reduced from a decade ago. Previously reported risk factors have not altered although 1/7 case occurred after duodenal hematoma. Long term sequele (pancreatic insufficiency) resulted in 1/7 cases. Patient survival was not affected by acute pancreatitis. 185 ERCP IN THE VERY OLD Rhody Fawaz, M.D.*. Gastroenterology, Comanche County Memorial Hosp, Lawton, OK. Purpose: There is limited data on ERCP performed in the very old population: clinical presentation, endoscopic findings, complications rates. Methods: Retrospective review of all ERCP performed on patients older than 90 years, between 5/1995–2/2002, to include: clinical presentation, endoscopic success rate, endoscopic findings and complications. Results: 26 patients, 18 Females and 8 Males, aged between 90 –99 years of age underwent 29 ERCPs in out institution. Major complaints and presentations were: abnormal liver enzymes (24), abdominal pain (18), abnormal imaging (140), painless jaundice (6), pancreatitis (5), weight loss (3), sepsis and bacteremia secondary to cholangitis (2). ERCP with suc-
Methods: Retrospective review from 1999 to 2001. Patient demographics and labs, length of stay, the indication for CT, ordering physician, and CT result were recorded. Severity of illness was assessed using the SAPS II score. Patients excluded with any of the following: pancreatitis not the principle reason for admission, patient discharged prior to obtaining CT, previous diagnosis of pancreatitis, lipase ⬍ 3 times the upper limit, and CT done without IV contrast. Variables associated with obtaining a CT were correlated using Fisher’s Exact test and two–sample t–test. Results: 108 patients met inclusion criteria. Of these, 58 underwent CT for evaluation of acute pancreatitis. There was no difference (all p⬎ 0.60) in markers of severity of illness in patients undergoing CT vs. no CT. There was a striking difference in length of stay (p ⫽ 0.0003), as patients not undergoing CT were discharged a mean of 3 days earlier. Most patients undergoing CT had alcoholic pancreatitis (p⫽0.047). There were a greater number of appropriate CT scans by the medical attending physicians and gastroenterology consultants in comparison with the resident housestaff and emergency room. In our 108 patients 75 had a prior ultrasound examination. Of those, 23 were reported as normal, and 13 of these 23 patients underwent CT. Conclusions: Physicians ordering CT scans for the evaluation of acute pancreatitis do so without regard to the severity of patient illness. These examinations prolong the length of stay dramatically such that costs from the test are substantial (charges⫽$4,700/CT at our institution). ER and medical resident personnel order inappropriate CT scans more often than consultants. An unremarkable ultrasound does not appear to greatly impact subsequent request for a CT scan. Continued refinement and dissemination of appropriate guidelines is needed.
183 DO ENDOSCOPIC STIGMATA OF STONE MIGRATION PREDICT THE PRESENCE OF COMMON BILE DUCT STONES? Vaman S. Jakribettuu, M.D., Girish Mishra, M.D., John H. Gilliam, M.D., Peter C. McNally, D.O. and Benoit C. Pineau, M.D.*. Section of Gastroenterology, University of Colorado Health Sciences Center, Denver, CO and Section of Gastroenterology, Wake Forest University Baptist Medical Center, Winston–Salem, NC. Purpose: Endoscopic stigmata of stone migration (ESSM) indicative of recent stone passage through the ampulla include: erythema and edema of the major papilla, patulous papillary os, presence of a choledocho– duodenal fistula, and/or sludge at the papillary os. No data are available on the accuracy of ESSM to predict the presence or absence of CBDS. The aim was to prospectively evaluate the prevalence and utility of ESSM to predict the presence of common bile duct stone (CBDS) Methods: 77 consecutive patients referred for management of suspected CBDS were included in the study. Patients underwent ERCP with careful inspection of the major papilla followed by selective cannulation and cholangiography. Balloon occlusion cholangiography was used as the gold standard for the detection of common bile duct stones. Results: Twenty–two (29%) of the 77 patients had ESSM on endoscopy (Table 1). ESSM were seen in similar proportion of patients presenting with gallstone pancreatitis (GP) and those with other presentations (30% Vs. 28%, p ⫽ NS). Twenty–9 (38%) of the 77 patients had CBDS. CBDS were more frequently found when ESSM were present but the difference was not statistically significant (ESSM present, 45% vs ESSM absent, 34%; p ⫽ NS). In the subgroup of patients with GP, CBDS were less common in patients with ESSM when compared to those without ESSM, but the difference was not statistically significant (ESSM present, 33% vs ESSM absent, 43%; p ⫽ NS). In the subgroup of 57 patients without GP, the presence of ESSM predicted the presence of CBDS (ESSM present, 50% vs ESSM absent, 31%; p ⬍ 0.05). Conclusions: Endoscopic stigmata of stone migration are present in 29% of patients with suspected CBDS. In the absence of gallstone pancreatitis, ESSM are associated with a higher probability of finding CBDS. Hence,
Abstracts
S61
ESSM do not exclude the presence of CBDS and should not alter the management plan in any patient subgroup. Table 1: CBDS and endoscopic stigmata of stone migration (ESSM) Condition (n)
CBDS present, ESSM present
CBDS present, ESSM absent
All patients (77) Pancreatitis (20) Other presentations (57)
10/22 (45%) 2/6 (33%) 8/16 (50%)
19/55 (34%) 6/14 (43%) 13/41 (31%)
P ⫽ NS P ⫽ NS P ⬍ 0.05
184 ACUTE PANCREATITIS FOLLOWING HEMATOPOIETIC STEM CELL TRANSPLANTATION IN CHILDREN Khalid Khan, M.B.Ch.B., Stella Davies, M.D., Rajaram Nagarajan, M.D. and Sally Weisdorf–Schindele, M.D.*. Pediatrics, University of Minnesota, Minneapolis, MN. Purpose: A decade ago acute pancreatitis was reported in 3.5% of children after bone marrow transplantation and associated with a poor outcome. Reports on adults have indicated that pancreatitis may be present in 30% of cases. We examined prevalence and risk factors for acute pancreatitis in the present day and how these have altered due to changes in transplant protocols. Methods: Data was reviewed on documented cases of pancreatitis in stem cell transplants performed from January 1996 –December 2001. The diagnosis was based on amylase and or lipase elevation (3⫻ normal) associated with abdominal pain in 7/8 and CT and laboratory findings in 1. Results: Eight cases of pancreatitis occurred in 445 transplants (1.8%). There were 4 males, age range 2–17 years (mean 10). Post transplant days ranged from 25–240 (mean 97.6). Symptoms in 7/8 lasted an average of 9.3 days (range 3–21), similarly enzyme elevation was present for 9.4 days (range 2–21). One female died 2 days after presentation from cardiac disease. Associated factors included a primary diagnosis of acute lymphoblastic leukemia (n ⫽ 2), acute myloid leukemia (n ⫽ 2), Fanconi’s anemia (n ⫽ 2), a matched unrelated marrow transplant (n ⫽ 5), drugs; methylprednisone (n ⫽ 5), cyclosporin A (n ⫽ 5) and bactrim (n ⫽ 6). One patient was on L–asparaginase and vincristine. Post transplant complications prior to pancreatitis included renal failure (n ⫽ 4), graft versus host disease (n ⫽ 4), cytomegalovirus infection (n ⫽ 3), hypertryglycedidemia (n ⫽ 3), and duodenal hematoma (n ⫽ 1). Radiology (CT and USS) was normal in all but 2 cases (a pseudocyst and peripancreatic inflammation). Apart from stopping oral intake and nasogastric suction treatment included octreotide (n ⫽ 1) and pancreatic enzymes (n ⫽ 1). All patients were on broad spectrum antibiotics and parenteral nutrition prior to pancreatitis. Complications occurred in 2 (exocrine pancreatic insufficiency and pseudocyst formation). No deaths occurred as a result of pancreatitis. Conclusions: The prevalence of acute pancreatitis after stem cell transplantation is reduced from a decade ago. Previously reported risk factors have not altered although 1/7 case occurred after duodenal hematoma. Long term sequele (pancreatic insufficiency) resulted in 1/7 cases. Patient survival was not affected by acute pancreatitis. 185 ERCP IN THE VERY OLD Rhody Fawaz, M.D.*. Gastroenterology, Comanche County Memorial Hosp, Lawton, OK. Purpose: There is limited data on ERCP performed in the very old population: clinical presentation, endoscopic findings, complications rates. Methods: Retrospective review of all ERCP performed on patients older than 90 years, between 5/1995–2/2002, to include: clinical presentation, endoscopic success rate, endoscopic findings and complications. Results: 26 patients, 18 Females and 8 Males, aged between 90 –99 years of age underwent 29 ERCPs in out institution. Major complaints and presentations were: abnormal liver enzymes (24), abdominal pain (18), abnormal imaging (140), painless jaundice (6), pancreatitis (5), weight loss (3), sepsis and bacteremia secondary to cholangitis (2). ERCP with suc-