- Email: [email protected]
Enteral feeding stimulates pancreatic enzyme secretion during acute pancreatitis
outcome and MRI severity score. Results: Thirty-nine patients (23 males, 16 females), with a median age of 47 years (range:15-86) were studied during a 21-month period. AP was considered of biliary etiology in 19 patients (48.7%). Ranson score was > or = to 3 for 18 patients (46%). A strong correlation was demonstrated between CTSI and MRSI on admission (r = 0.863, p or = to 3 (respectively p=0.058 and p=0.002) and a MRSI > or = to 3 (respectively p=0.003 and p=0.001). S-MRCP detected early pancreatic duct leakage in three patients (7.6%)~ who required further endoscopic drainages procedures. Conclusions: MRI is a reliable method for staging AP severity and it has prognostic value for clinical outcome It can also reveal pancreatic duct rupture, which can occur early in the course of AP Furthermore, S-MRCP can detect pancreatic duct irregularity and abnormal duodenal filling, which are associated with severe AP.
significant at mukivariate analysis. The probability of a biliary origin of AP was 1/( 1 + anti1og(4.6967-0.0656 X age + 1.1208 X sex - 0.6909 X ALAT*)) (**). At ages 50 and 60 years, the respective sensitivities and specificities were: 73%, 61% and 65%, 80%. With an elevated ALAT at 2 times or 3 times normal, respective sensitivities and specificities were 74%, 61% and 84%, 91% Conclusion: a) EUS confirms a biliary cause for AP in 15% of cases where standard non invasive imaging was non diagnostic b) when EUS is performed to confirm/exclude a biliary origin of AP, age, sex and ALAT at admission are sufficient factors in predicting a biliary cause. * ALAT at admission times upper normal limit; (**) sex = 1 for male, 0 for female.
656 A New Scoring System for the Assessment of Acute Pancreatitis Severity Gonzalo Alvarez Del Real, Darwin L. Couwell, Parah Khandwala, Gregory Zuccaro Jr., Alejandro C. Arroliga Background. Current prognostic scores for the assessment of acute pancreatitis severity are complex (APACHE ll) or not completed until 48 hrs after admission (Ranson's criteria). A simpler scoring system to predict severity of acute pancreatitis would be desirable. Aim. To develop and validate a new scoring system to predict acute pancreatitis severity on admission. Methods. Retrospective study of patients with acute pancreatins admitted from the years 1997 to 2000. Thirty-four biological and biochemical candidate risk factors for severity were considered. Significant factors from univariate analyses were considered in a multivariate logistic regression model to develop a new scoring system for the assessment of acute pancreatitis severity. Results. The new scoring system predicts severity based on gender, etiology, heart rate, hemoglobin, hematocrit, creatinine and albumin, with scores ranging from 0-12. This scoring system was applied to it's generating dataset (471 patients): 87% of the patients with admission severity score >7 had severe acute pancreatitis. Acute pancreatitis severity on admission was then determined on a separate validation set of 110 patients based on the development of local complications and/or organ failure. 74/110 were found to have severe acute pancreatitis. The APACHE 11(---8 points), Ranson's criteria (-->3points) and new scoring system (->7 points) were also used to assess severity on this validation set. Statistical diagnostics are shown in table. Conclusion. A new prognostic scoring system for acute pancreatitis has been developed utilizing simple clinical admission data. This scoring system is simpler than APACHE I[ and is obtained before the complete Ranson's criteria. It outperforms these two scoring systems as APACHE II is overly sensitive for the assessment of acute pancreatitis severity (has a high false positive rate) and Ranson's criteria has a low sensitivity. Clinical implication: Further evaluation of this new scoring system in a prospective trial is warranted.
654
Pancreatic CT Guided-fine Needle Aspiration in the Diagnosis of Infected Acute Pancreatitis. The Value of Clinical Criteria Irma E. Calderon Lozano, Eduardo Mendoza Faerie, Dora A. Garcia Cantu, Jose A Gonzalez Gonzalez, Hector J. Maldonado Garza BACKGROUND: The exact time or guidelines to perform CT- fine needle aspiration (CTFNA) to document pancreatic infection (Pl) are still undefined. AIM: To assess the value of clinical criteria for suspiction of pancreatic infection (SPI) at or after the 7th day of the onset of acute pancreatitis (AP) in detecting the presence of PI. METHODS: Since Jan 2000 to May 2002 all patients(pts)with AP were included. Clinical criteria of SPI were taken at or after the 7th day of the onset of AP: fever -> 38 centigrades, leukocytosis > 12,000/ mm3, clinical deterioration and/or organ failure (OF) in the absence of extrapancreatic infection. Pts with SPI underwent CT-FNA to rule out P[. We studied: gender, age, etiology, onset of AP, SPI criteria, Balthazar score, CT-FNA complications, Gram/culture, length of hospital stay, surgery and death. Pts with Ranson ->3 or with any SPI criteria received antibiotic prophylaxis. The t-Student test and Chi-square were used for comparisons. RESULTS: 226 pts with AP, 31 (14%) had SPI. M/F 21/10 pts, age 39 yrs (17-70). Etiology: biliary 17 (55%), alcoholic 12 (39%) and idiopathic 2(6%). 1 pts was Balthazar B and 29 pts were C or more. 33 CT-FNAs were done in 30 pts without complications. P] was detected in 20 pts. SPI criteria are shown in the table. The mean time to CT-FNA was 10.8 -+5 days (7 - 33),in the P[ and non-PI pts were 12.3 -+5.9 days and 8.4+1.6 days (p=NS). PI diagnosis was done by Gram stain in 18/20 pts (90%) or culture in 2/20 pts (10%). Monomicrobial infection was in 75% of pts and polymicrobial in 25% of pts. The most commonly isolated microorganisms were Staphylococcus spp 30%, Pseudoraonas spp 30%, E. faecalis 20% and E. coil 15%. All pts with PI were confirmed by surgery. Length of hospital stay for PI and non PI was 48 _+ 31 days(9 to 137) and 17.6-+8.7 days(8 to 37) respectively (p = 0.003) Only 1/195 pts without SP1 criteria died. 10/31 pts with SPI criteria died: 8 had PI, 1 had no infection, and 1 died before the CT-FNA. All pts died of OF. OF at the time of diagnosis of PI earned a mortality of 71% (5/7pts). SPI criteria had a sensitivity of 100 %, specificity 95%, PPV 66 %, and NPV 100%. CONCLUSION: The SPI criteria at or after the 7th day of the onset of AP are useful to the clinician in making the decision and defining the time to perform a CT-FNA to diagnose PI.
StaG'~ (Ragno~cs of vailda~on set of paUentsw~ acute pancmeBls: % and (95% C~lmr. val)
,~16~tlty ,S~ Poaltlvt P r ~ c t ~ Value llegallve Predictive Value
Fever Leukocytosis Fever + leukocytosis Fever + leukocytosis t clinical dMedorabon Fever + leukocytosis * OF Leukocytosls + OF Fever + OF
Non-pl (.-t0)
3 0 5 5 6 1 0
1 1 3 2 2 0 1
Ranmn'aOlteda 5.6 (1,19) 91.9 (83, 97)
80.0 (44, 97)
32.7 (24, 42)
25.0 (3, 65)
72,0 (62, 81)
---
66.7 (57, 76)
Enteral Feeding Stimulates Pancreatic Enzyme Secretion during Acute Pancreatitis Stephen J. O'Keefe, Ronzo B. Lee, Scan McGarr Several recent comparative clinical trials have concluded that enteral feeding is superior to TPN in the management of acute pancreatitis. Although studies of ours have shown that the secretory response to enteral feeding is reduced in AP, it remains possible that the response may be higher than the basal rates observed during TPN and bowel rest. Consequently, we have compared secretory responses over 4 hours in 11 patients in the initial stages of acute pancreatitis given duodenal mfusinns of elemental formula diets (EN:n= 10) or TPN and bowel rest (TPN:n=3). Ranson's score varied from 0-8 in the EN group and 3-5 in TPN group; 2 patients were studied on both diets during the same day. All diets provided amino acids at 1.5g/Kg/d and energy at 30Kcal/Kg/d. Secreted enzymes were recovered by perhision of 5% PEG-labeled saline (30Oral/h) at the level of the ampulla and distal duodenal aspiration. Results were evaluated by comparison to similar measurements made m healthy controls (OKeefe AJP 2002). Table (group means(SE))shows that although the pancreatic enzyme secretory response to enteral feeding was lower in patients than healthy volunteers, the secretion rate was higher than that measured in patients on TPN and bowel rest. In the 2 patients studied on both diets, secretion was lower during TPN Conclusion: Elemental formula feeding into the upper small intestine does not rest the pancreas. Consequently, the superior outcome with of enteral feeding during acute pancreatitis is unrelated to the effects of feeding on the pancreas, but probably to indirect factors, such as reduced septic and metabolic complications. Further studies are needed to determine whether enteral feeding can be made safer by distal intestinal feeding, in the hope of avoiding stimulation.
655
Echoendoscopy Modifies Classical Predictive Criteria of a Biliary Origin of Acute Pancreatitis: Prospective Mnlticentre French Study Philippe Levy, A Boruchowicz, P Hastier, A. Pariente, T. Thevenot, Jl Frossard, L. Buscail, Francois Mauvais, Jc Duchemann, A. Courtier, A. Cortot, J1 Gineston, R. Laugier, H. Licht, Philippe Ruszniewski To-date, no study on clinical and biological criteria predicting a bihary origqn for acute pancreatitis (AP) has included endoscopic ultrasound (EUS) as a reference examination to confirm biliary stones. Since the publication of studies devoted to this topic, several other causes of AP have been described and thus were not taken into account. Aim and methods: determine the best markers of predicting a bihary origin of AP. Examine whether confirmation of AP due to a biliary cause could be made on traditional non invasive imaging methods (US, CT-scan) or EUS. Absence of biliary stones was always confirmed at EUS and only 1st episodes of AP were included Results: 213 patients (male: 56%; median age: 56 yrs) were prospectively included in 25 centres. Causes of AP were bdiary (62%), alcoholic (25%) and other (13%). EUS was the sole method making the diagnosis of a biliary cause in 15% of biliary AP where traditional imaging was negative. The delay between symptom onset and admission was < 24h, 24-48h or > 48h in respectively 64.4%, 15.6% and 20% of patients. At univariate analysis, the following parameters were predictive of a bdiary origin: age (P<0.0001), female sex (0.0001), declared alcohol consumption (0.0001), elevated ASAT and ALAT on admission (0.0001), GGT (0.01), ALP (0.002), total bilimbni (0.03), lipase (0.0001), MCV (0.0001) Only age (p<0.0001), sex (0.0008) and ALAT (0.0004) remained
AGA Abstracts
APACHEII 100.0 (90, 100) 0.0 (0, 5)
657
SPI Criteria for CT.FNA
Pi (0,20)
Clinical Pro~oetlc Model 22,2 (10, 39) 97.3 (01,100)
Tqfl~in (lu/h) Amylase (itS) Upase (lu/h/1000) Healthy voln ED 439(27) 11791(1106) 610(61) Healthy vol TPN 266(49)'* 1064{272) ~ 76(14) ~ Palkmts ED 209(33) 9165(3787) 235(73) e~leds I"PN 34(5}-~674(137)* 13(2)+~ Sta~slk~s: Mann Whi~y NP "p < 0.05, ' ~ p<0,005 versus volunteers ED; + p< 0.05 vs pa0ents EO
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significant at mukivariate analysis. The probability of a biliary origin of AP was 1/( 1 + anti1og(4.6967-0.0656 X age + 1.1208 X sex - 0.6909 X ALAT*)) (**). At ages 50 and 60 years, the respective sensitivities and specificities were: 73%, 61% and 65%, 80%. With an elevated ALAT at 2 times or 3 times normal, respective sensitivities and specificities were 74%, 61% and 84%, 91% Conclusion: a) EUS confirms a biliary cause for AP in 15% of cases where standard non invasive imaging was non diagnostic b) when EUS is performed to confirm/exclude a biliary origin of AP, age, sex and ALAT at admission are sufficient factors in predicting a biliary cause. * ALAT at admission times upper normal limit; (**) sex = 1 for male, 0 for female.
656 A New Scoring System for the Assessment of Acute Pancreatitis Severity Gonzalo Alvarez Del Real, Darwin L. Couwell, Parah Khandwala, Gregory Zuccaro Jr., Alejandro C. Arroliga Background. Current prognostic scores for the assessment of acute pancreatitis severity are complex (APACHE ll) or not completed until 48 hrs after admission (Ranson's criteria). A simpler scoring system to predict severity of acute pancreatitis would be desirable. Aim. To develop and validate a new scoring system to predict acute pancreatitis severity on admission. Methods. Retrospective study of patients with acute pancreatins admitted from the years 1997 to 2000. Thirty-four biological and biochemical candidate risk factors for severity were considered. Significant factors from univariate analyses were considered in a multivariate logistic regression model to develop a new scoring system for the assessment of acute pancreatitis severity. Results. The new scoring system predicts severity based on gender, etiology, heart rate, hemoglobin, hematocrit, creatinine and albumin, with scores ranging from 0-12. This scoring system was applied to it's generating dataset (471 patients): 87% of the patients with admission severity score >7 had severe acute pancreatitis. Acute pancreatitis severity on admission was then determined on a separate validation set of 110 patients based on the development of local complications and/or organ failure. 74/110 were found to have severe acute pancreatitis. The APACHE 11(---8 points), Ranson's criteria (-->3points) and new scoring system (->7 points) were also used to assess severity on this validation set. Statistical diagnostics are shown in table. Conclusion. A new prognostic scoring system for acute pancreatitis has been developed utilizing simple clinical admission data. This scoring system is simpler than APACHE I[ and is obtained before the complete Ranson's criteria. It outperforms these two scoring systems as APACHE II is overly sensitive for the assessment of acute pancreatitis severity (has a high false positive rate) and Ranson's criteria has a low sensitivity. Clinical implication: Further evaluation of this new scoring system in a prospective trial is warranted.
654
Pancreatic CT Guided-fine Needle Aspiration in the Diagnosis of Infected Acute Pancreatitis. The Value of Clinical Criteria Irma E. Calderon Lozano, Eduardo Mendoza Faerie, Dora A. Garcia Cantu, Jose A Gonzalez Gonzalez, Hector J. Maldonado Garza BACKGROUND: The exact time or guidelines to perform CT- fine needle aspiration (CTFNA) to document pancreatic infection (Pl) are still undefined. AIM: To assess the value of clinical criteria for suspiction of pancreatic infection (SPI) at or after the 7th day of the onset of acute pancreatitis (AP) in detecting the presence of PI. METHODS: Since Jan 2000 to May 2002 all patients(pts)with AP were included. Clinical criteria of SPI were taken at or after the 7th day of the onset of AP: fever -> 38 centigrades, leukocytosis > 12,000/ mm3, clinical deterioration and/or organ failure (OF) in the absence of extrapancreatic infection. Pts with SPI underwent CT-FNA to rule out P[. We studied: gender, age, etiology, onset of AP, SPI criteria, Balthazar score, CT-FNA complications, Gram/culture, length of hospital stay, surgery and death. Pts with Ranson ->3 or with any SPI criteria received antibiotic prophylaxis. The t-Student test and Chi-square were used for comparisons. RESULTS: 226 pts with AP, 31 (14%) had SPI. M/F 21/10 pts, age 39 yrs (17-70). Etiology: biliary 17 (55%), alcoholic 12 (39%) and idiopathic 2(6%). 1 pts was Balthazar B and 29 pts were C or more. 33 CT-FNAs were done in 30 pts without complications. P] was detected in 20 pts. SPI criteria are shown in the table. The mean time to CT-FNA was 10.8 -+5 days (7 - 33),in the P[ and non-PI pts were 12.3 -+5.9 days and 8.4+1.6 days (p=NS). PI diagnosis was done by Gram stain in 18/20 pts (90%) or culture in 2/20 pts (10%). Monomicrobial infection was in 75% of pts and polymicrobial in 25% of pts. The most commonly isolated microorganisms were Staphylococcus spp 30%, Pseudoraonas spp 30%, E. faecalis 20% and E. coil 15%. All pts with PI were confirmed by surgery. Length of hospital stay for PI and non PI was 48 _+ 31 days(9 to 137) and 17.6-+8.7 days(8 to 37) respectively (p = 0.003) Only 1/195 pts without SP1 criteria died. 10/31 pts with SPI criteria died: 8 had PI, 1 had no infection, and 1 died before the CT-FNA. All pts died of OF. OF at the time of diagnosis of PI earned a mortality of 71% (5/7pts). SPI criteria had a sensitivity of 100 %, specificity 95%, PPV 66 %, and NPV 100%. CONCLUSION: The SPI criteria at or after the 7th day of the onset of AP are useful to the clinician in making the decision and defining the time to perform a CT-FNA to diagnose PI.
StaG'~ (Ragno~cs of vailda~on set of paUentsw~ acute pancmeBls: % and (95% C~lmr. val)
,~16~tlty ,S~ Poaltlvt P r ~ c t ~ Value llegallve Predictive Value
Fever Leukocytosis Fever + leukocytosis Fever + leukocytosis t clinical dMedorabon Fever + leukocytosis * OF Leukocytosls + OF Fever + OF
Non-pl (.-t0)
3 0 5 5 6 1 0
1 1 3 2 2 0 1
Ranmn'aOlteda 5.6 (1,19) 91.9 (83, 97)
80.0 (44, 97)
32.7 (24, 42)
25.0 (3, 65)
72,0 (62, 81)
---
66.7 (57, 76)
Enteral Feeding Stimulates Pancreatic Enzyme Secretion during Acute Pancreatitis Stephen J. O'Keefe, Ronzo B. Lee, Scan McGarr Several recent comparative clinical trials have concluded that enteral feeding is superior to TPN in the management of acute pancreatitis. Although studies of ours have shown that the secretory response to enteral feeding is reduced in AP, it remains possible that the response may be higher than the basal rates observed during TPN and bowel rest. Consequently, we have compared secretory responses over 4 hours in 11 patients in the initial stages of acute pancreatitis given duodenal mfusinns of elemental formula diets (EN:n= 10) or TPN and bowel rest (TPN:n=3). Ranson's score varied from 0-8 in the EN group and 3-5 in TPN group; 2 patients were studied on both diets during the same day. All diets provided amino acids at 1.5g/Kg/d and energy at 30Kcal/Kg/d. Secreted enzymes were recovered by perhision of 5% PEG-labeled saline (30Oral/h) at the level of the ampulla and distal duodenal aspiration. Results were evaluated by comparison to similar measurements made m healthy controls (OKeefe AJP 2002). Table (group means(SE))shows that although the pancreatic enzyme secretory response to enteral feeding was lower in patients than healthy volunteers, the secretion rate was higher than that measured in patients on TPN and bowel rest. In the 2 patients studied on both diets, secretion was lower during TPN Conclusion: Elemental formula feeding into the upper small intestine does not rest the pancreas. Consequently, the superior outcome with of enteral feeding during acute pancreatitis is unrelated to the effects of feeding on the pancreas, but probably to indirect factors, such as reduced septic and metabolic complications. Further studies are needed to determine whether enteral feeding can be made safer by distal intestinal feeding, in the hope of avoiding stimulation.
655
Echoendoscopy Modifies Classical Predictive Criteria of a Biliary Origin of Acute Pancreatitis: Prospective Mnlticentre French Study Philippe Levy, A Boruchowicz, P Hastier, A. Pariente, T. Thevenot, Jl Frossard, L. Buscail, Francois Mauvais, Jc Duchemann, A. Courtier, A. Cortot, J1 Gineston, R. Laugier, H. Licht, Philippe Ruszniewski To-date, no study on clinical and biological criteria predicting a bihary origqn for acute pancreatitis (AP) has included endoscopic ultrasound (EUS) as a reference examination to confirm biliary stones. Since the publication of studies devoted to this topic, several other causes of AP have been described and thus were not taken into account. Aim and methods: determine the best markers of predicting a bihary origin of AP. Examine whether confirmation of AP due to a biliary cause could be made on traditional non invasive imaging methods (US, CT-scan) or EUS. Absence of biliary stones was always confirmed at EUS and only 1st episodes of AP were included Results: 213 patients (male: 56%; median age: 56 yrs) were prospectively included in 25 centres. Causes of AP were bdiary (62%), alcoholic (25%) and other (13%). EUS was the sole method making the diagnosis of a biliary cause in 15% of biliary AP where traditional imaging was negative. The delay between symptom onset and admission was < 24h, 24-48h or > 48h in respectively 64.4%, 15.6% and 20% of patients. At univariate analysis, the following parameters were predictive of a bdiary origin: age (P<0.0001), female sex (0.0001), declared alcohol consumption (0.0001), elevated ASAT and ALAT on admission (0.0001), GGT (0.01), ALP (0.002), total bilimbni (0.03), lipase (0.0001), MCV (0.0001) Only age (p<0.0001), sex (0.0008) and ALAT (0.0004) remained
AGA Abstracts
APACHEII 100.0 (90, 100) 0.0 (0, 5)
657
SPI Criteria for CT.FNA
Pi (0,20)
Clinical Pro~oetlc Model 22,2 (10, 39) 97.3 (01,100)
Tqfl~in (lu/h) Amylase (itS) Upase (lu/h/1000) Healthy voln ED 439(27) 11791(1106) 610(61) Healthy vol TPN 266(49)'* 1064{272) ~ 76(14) ~ Palkmts ED 209(33) 9165(3787) 235(73) e~leds I"PN 34(5}-~674(137)* 13(2)+~ Sta~slk~s: Mann Whi~y NP "p < 0.05, ' ~ p<0,005 versus volunteers ED; + p< 0.05 vs pa0ents EO
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