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M1274 Obesity in Acute Pancreatitis Patients: Correlation with Disease Severity and Performance of Apache-0 Score
AGA Abstracts
pancreatic necrosis (p=0.035). Conclusions: In patients with AP, Balthazar grade of an early CT scan correlated with Ranson score, presence of SIRS, and number of MOF and was useful in prediction of clinical course. But, CTSI did not correlate with Ranson score. Pancreatic necrosis occurred more often in patients with high Balthazar grade.
M1275 Time Trends in Incidence of Acute Pancreatitis in Lüneburg: A PopulationBased Study Paul G. Lankisch, Mirwais Karimi, Anja Bruns, Patrick Maisonneuve, Albert B. Lowenfels Background and aim: Recent reports have suggested an increase in the incidence of gallstonerelated pancreatitis and a decreased of alcoholic-related pancreatitis over the past decades (1). The aim of this study was to investigate trends in the incidence of acute pancreatitis (AP) by etiology, in Lüneburg, a population-based area from North Germany over a 20year period. Material and methods: This study includes 609 patients (339 men, 270 women) admitted for a first attack of AP in the Municipal Center of Lüneburg during 1987-2006. Rates of AP were calculated for 5-year periods and standardized according to the World population in order to adjust for the variation of the age distribution of the general population. Results: Over the last 20 years, the age-standardized rate (ASRW) of AP was 16.0 per 100.000-year in men and 10.2 per 100.000-year in women. It did not varied significantly over time. When stratified by subtype of AP, neither the incidence of alcoholic AP nor that of biliary AP varied over time (table 1). Considering the clinical characteristics of the attacks, we found that the severity of AP decreased over time. From 1987-1991 to 2002-2006, the proportion of patients with a Ranson score ≥2 decreased from 33% to 20% (p=0.0009), the surgery rate from 29% to 6% (p<.0001) and the proportion of patients with necrosis, organ failure or who died decreased from 19% to 9%. Conclusion: Unlike in other populations (2), the incidence of AP did not increased over the last two decades in Lüneburg, but both the severity of the attacks and the surgical treatment has decreased significantly. 1.Lindkvist B et al, Trends in the incidence of acute pancreatitis in a Swedish population: Is there really an increase? Clin Gastrenterol Hepatol 2004; 2:831-837 2.Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: A systematic review. Pancreas 2006;33:323-30.
M1273 The Harmless Acute Pancreatitis Score: A Convenient New Means of Assessing Prognosis On Admission Evaluated in 1008 Patients with a First Attack of Acute Pancreatitis Paul G. Lankisch, Bettina Weber-Dany, Katrin Hebel, Patrick Maisonneuve, Albert B. Lowenfels Introduction: There is currently no specific treatment for acute pancreatitis; the only course available is to admit the patient to the intensive care unit, where the beds are scarce and costly and the therapy is also expensive. These resources should be reserved for patients in whom a severe course of the disease can be expected. The prediction of severe pancreatitis on admission is difficult, as the existing all prognostic scores are relatively insensitive, complicated or not available on admission. We identified a score which indicates a “harmless” pancreatitis: Harmless Acute Pancreatitis Score (HAPS), defined as no rebound tenderness and guarding, normal hematocrit and serum creatinine. If these parameters were present, the test was considered to be positive. Patients and methods: The HAPS was retrospectively evaluated in 608 patients with a first acute pancreatitis admitted the Municipal Hospital of Lueneburg between 1987 and 2004. Prospectively the score test was tested in 401 patients together with the members of the Arbeitsgemeinschaft leitender gastroenterologischer Krankenhausärzte (ALGK). All patients underwent contrast-enhanced CT within 72 h after admission. A severe course of the disease was defined as need for artificial ventilation or dialysis or pancreatic necrosis at any time during hospitalization, or death. Results: With the exception of four patients in the retro- and one patient in the prospective study patients with positive HAPS had no pancreatic necrosis, not a severe course of the disease and did not die from pancreatitis. The correlation of HAPS with the severity of the disease is shown in the table 1. The same results were obtained in comparison to necrotizing pancreatitis and mortality. Conclusion: The HAPS we evaluated in 1008 patients enables the attending physician of any hospital to detect within 30 min after admission those patients with acute pancreatitis whose disease will run a mild course. It helps him to decide with great accuracy which patients require intensive care and to save the hospital substantial costs.
Table 1 M1276 Trypsinogen Activation Peptide (TAP) Predicts the Development of Pulmonary Insufficiency in Patients with Interstitial Pancreatitis Ian Wall, Konstantin Vaisman, Nison Badalov, Jack Braha, Jian Jun Li, Scott Tenner M1274
The management of patients with acute pancreatitis is often affected by difficulty in distinguishing patients at risk for complications, such as organ failure, early in the course of the disease. We have previously shown that elevated urinary trypsinogen activation peptide (TAP) can help determine severity in patients with acute pancreatitis. Most patients included in our prior studies had pancreatic necrosis. However, it has been established that as many as half of the patients with organ failure do not have pancreatic necrosis. The ability of TAP to determine which patients with interstitial pancreatitis are at risk for developing organ failure has not been studied. In order to determine the role of TAP in predicting the development of organ failure in patients with interstitial pancreatitis, the following study was performed. After informed consent was obtained, seventeen consecutive patients with acute interstitial pancreatitis were enrolled. All patients underwent a contrast enhanced CT scan within 48 hours of admission. If complications developed, a repeat CT would be performed to confirm the absence of pancreatic necrosis. A sample of urine was submitted within 12 hours of admission for analysis of TAP level. All patients were followed closely until discharge. Of the 17 patients with interstitial pancreatitis, 4 patients developed pulmonary insufficiency and were admitted to the intensive care unit. Pulmonary insufficiency was defined by the Atlanta Symposium as a persistent PA02 < 60 mm Hg requiring oxygen supplementation. One patient was not included in the final analysis as pancreatic necrosis developed. All patients with pulmonary insufficency did not develop any other signs of organ failure. The urinary TAP level in patients who developed pulmonary insufficiency was signifcantly higher than patients without pulmonary insufficiency, 27.5+6.8 mM/dl vs 7.4+1.8 mM/dl (p = 0.02). All patients with pulmonary insufficiency had a urinary TAP greater than 10 mM/dl. The negative predictive value of TAP in determining the development of pulmonary insufficiency was 100%. The hematocrit (HCT) on admission and at 24 hours did not significantly differ among the two groups (admission HCT: 40.1+6.1 % vs 42.5+4.3 % (p= 0.4). In conclusion, obtaining a urinary TAP level early in the course of the disease can assist clinicians in determining which patients with intersitial pancreatitis will develop pulmonary insufficiency.
Obesity in Acute Pancreatitis Patients: Correlation with Disease Severity and Performance of Apache-0 Score Paul G. Lankisch, Bettina Weber-Dany, Patrick Maisonneuve, Albert B. Lowenfels Almost 20 years ago we were the first to recognize that obesity is a negative prognostic factor in acute pancreatitis (P.G. Lankisch and C.A. Schirren, Pancreas 5:626-629, 1990). A number of studies have been published in the meantime with differing results. The aims of our prospective multicentre study with members of the Arbeitsgemeinschaft leitender gastroenterologischer Krankenhausärzte (ALGK) were to assess whether obesity correlates with necrotizing pancreatitis, severe course of the disease, and mortality and to investigate whether adding obesity to the APACHE-II score improves the value of this prognostic score (C.D. Johnson et al., Pancreatology 4:1-6, 2004). Patients and methods: The study included 419 patients with acute pancreatitis (aetiology: biliary 50%, alcoholic 28%, other 8%, idiopathic 14%). All patients underwent contrast-enhanced computed tomography, scored according to Balthazar (BS), and were checked for early and late organ failure. A severe course of the disease was defined as need for artificial ventilation or dialysis or necrosis (BS >4) at any time during hospitalization, or death. Obesity was scored numerically according to body mass index: 0 = normal (BMI <26; 35% of the patients); 1 = overweight (BMI 2630; 36%); 2 = obese (BMI >30; 29%). Receiver-operating curves were calculated using admission APACHE-II and APACHE-0 scores Results: A high BMI was significantly associated with necrotizing pancreatitis (p=0.02), severe course (p=0.002) and death (p=0.03). When patients were split into the four aetiological categories, the correlation remained significant for patients with biliary pancreatitis (p=0.03-0.05). Adding obesity to the APACHE-II score slightly increased the predictive value of the score for necrotizing pancreatitis and severe course of the disease in patients with biliary acute pancreatitis (table1). Conclusion: Obesity is not only a risk factor for the development of local and systemic complications in acute pancreatitis but also increases the mortality of this disease. The APACHE-O score is slightly superior to the APACHE-II score in biliary acute pancreatitis only.
M1277 Quality of Life One Year After a Single Attack of Acute Pancreatitis B.W. Marcel Spanier, Marcel.G.W. Dijkgraaf, Marco Bruno Background: In 2003 a prospective cohort study of acute pancreatitis (AP) in the province of Northern Holland was initiated (EARL study). The disease spectrum of AP ranges from mild and self limiting (80-90%) to a rapidly progressive fulminate illness with morbidity rates up to 30-50%. Data regarding the burden of an attack of AP on quality of life (QoL) are very scarce. The aim of the present study is to investigate the QoL one year after a single attack of AP. Methods: Patients were included from 18 hospitals. Hospital records and nursing reports were reviewed to assess the severity of AP, etiological factors, hospital stay, complications and co-morbidity. QoL evaluations were performed one year after the attack of AP using the validated EORTC QLQ C-30 (3.0) questionnaire. Questionnaires returned
AGA Abstracts
A-374
pancreatic necrosis (p=0.035). Conclusions: In patients with AP, Balthazar grade of an early CT scan correlated with Ranson score, presence of SIRS, and number of MOF and was useful in prediction of clinical course. But, CTSI did not correlate with Ranson score. Pancreatic necrosis occurred more often in patients with high Balthazar grade.
M1275 Time Trends in Incidence of Acute Pancreatitis in Lüneburg: A PopulationBased Study Paul G. Lankisch, Mirwais Karimi, Anja Bruns, Patrick Maisonneuve, Albert B. Lowenfels Background and aim: Recent reports have suggested an increase in the incidence of gallstonerelated pancreatitis and a decreased of alcoholic-related pancreatitis over the past decades (1). The aim of this study was to investigate trends in the incidence of acute pancreatitis (AP) by etiology, in Lüneburg, a population-based area from North Germany over a 20year period. Material and methods: This study includes 609 patients (339 men, 270 women) admitted for a first attack of AP in the Municipal Center of Lüneburg during 1987-2006. Rates of AP were calculated for 5-year periods and standardized according to the World population in order to adjust for the variation of the age distribution of the general population. Results: Over the last 20 years, the age-standardized rate (ASRW) of AP was 16.0 per 100.000-year in men and 10.2 per 100.000-year in women. It did not varied significantly over time. When stratified by subtype of AP, neither the incidence of alcoholic AP nor that of biliary AP varied over time (table 1). Considering the clinical characteristics of the attacks, we found that the severity of AP decreased over time. From 1987-1991 to 2002-2006, the proportion of patients with a Ranson score ≥2 decreased from 33% to 20% (p=0.0009), the surgery rate from 29% to 6% (p<.0001) and the proportion of patients with necrosis, organ failure or who died decreased from 19% to 9%. Conclusion: Unlike in other populations (2), the incidence of AP did not increased over the last two decades in Lüneburg, but both the severity of the attacks and the surgical treatment has decreased significantly. 1.Lindkvist B et al, Trends in the incidence of acute pancreatitis in a Swedish population: Is there really an increase? Clin Gastrenterol Hepatol 2004; 2:831-837 2.Yadav D, Lowenfels AB. Trends in the epidemiology of the first attack of acute pancreatitis: A systematic review. Pancreas 2006;33:323-30.
M1273 The Harmless Acute Pancreatitis Score: A Convenient New Means of Assessing Prognosis On Admission Evaluated in 1008 Patients with a First Attack of Acute Pancreatitis Paul G. Lankisch, Bettina Weber-Dany, Katrin Hebel, Patrick Maisonneuve, Albert B. Lowenfels Introduction: There is currently no specific treatment for acute pancreatitis; the only course available is to admit the patient to the intensive care unit, where the beds are scarce and costly and the therapy is also expensive. These resources should be reserved for patients in whom a severe course of the disease can be expected. The prediction of severe pancreatitis on admission is difficult, as the existing all prognostic scores are relatively insensitive, complicated or not available on admission. We identified a score which indicates a “harmless” pancreatitis: Harmless Acute Pancreatitis Score (HAPS), defined as no rebound tenderness and guarding, normal hematocrit and serum creatinine. If these parameters were present, the test was considered to be positive. Patients and methods: The HAPS was retrospectively evaluated in 608 patients with a first acute pancreatitis admitted the Municipal Hospital of Lueneburg between 1987 and 2004. Prospectively the score test was tested in 401 patients together with the members of the Arbeitsgemeinschaft leitender gastroenterologischer Krankenhausärzte (ALGK). All patients underwent contrast-enhanced CT within 72 h after admission. A severe course of the disease was defined as need for artificial ventilation or dialysis or pancreatic necrosis at any time during hospitalization, or death. Results: With the exception of four patients in the retro- and one patient in the prospective study patients with positive HAPS had no pancreatic necrosis, not a severe course of the disease and did not die from pancreatitis. The correlation of HAPS with the severity of the disease is shown in the table 1. The same results were obtained in comparison to necrotizing pancreatitis and mortality. Conclusion: The HAPS we evaluated in 1008 patients enables the attending physician of any hospital to detect within 30 min after admission those patients with acute pancreatitis whose disease will run a mild course. It helps him to decide with great accuracy which patients require intensive care and to save the hospital substantial costs.
Table 1 M1276 Trypsinogen Activation Peptide (TAP) Predicts the Development of Pulmonary Insufficiency in Patients with Interstitial Pancreatitis Ian Wall, Konstantin Vaisman, Nison Badalov, Jack Braha, Jian Jun Li, Scott Tenner M1274
The management of patients with acute pancreatitis is often affected by difficulty in distinguishing patients at risk for complications, such as organ failure, early in the course of the disease. We have previously shown that elevated urinary trypsinogen activation peptide (TAP) can help determine severity in patients with acute pancreatitis. Most patients included in our prior studies had pancreatic necrosis. However, it has been established that as many as half of the patients with organ failure do not have pancreatic necrosis. The ability of TAP to determine which patients with interstitial pancreatitis are at risk for developing organ failure has not been studied. In order to determine the role of TAP in predicting the development of organ failure in patients with interstitial pancreatitis, the following study was performed. After informed consent was obtained, seventeen consecutive patients with acute interstitial pancreatitis were enrolled. All patients underwent a contrast enhanced CT scan within 48 hours of admission. If complications developed, a repeat CT would be performed to confirm the absence of pancreatic necrosis. A sample of urine was submitted within 12 hours of admission for analysis of TAP level. All patients were followed closely until discharge. Of the 17 patients with interstitial pancreatitis, 4 patients developed pulmonary insufficiency and were admitted to the intensive care unit. Pulmonary insufficiency was defined by the Atlanta Symposium as a persistent PA02 < 60 mm Hg requiring oxygen supplementation. One patient was not included in the final analysis as pancreatic necrosis developed. All patients with pulmonary insufficency did not develop any other signs of organ failure. The urinary TAP level in patients who developed pulmonary insufficiency was signifcantly higher than patients without pulmonary insufficiency, 27.5+6.8 mM/dl vs 7.4+1.8 mM/dl (p = 0.02). All patients with pulmonary insufficiency had a urinary TAP greater than 10 mM/dl. The negative predictive value of TAP in determining the development of pulmonary insufficiency was 100%. The hematocrit (HCT) on admission and at 24 hours did not significantly differ among the two groups (admission HCT: 40.1+6.1 % vs 42.5+4.3 % (p= 0.4). In conclusion, obtaining a urinary TAP level early in the course of the disease can assist clinicians in determining which patients with intersitial pancreatitis will develop pulmonary insufficiency.
Obesity in Acute Pancreatitis Patients: Correlation with Disease Severity and Performance of Apache-0 Score Paul G. Lankisch, Bettina Weber-Dany, Patrick Maisonneuve, Albert B. Lowenfels Almost 20 years ago we were the first to recognize that obesity is a negative prognostic factor in acute pancreatitis (P.G. Lankisch and C.A. Schirren, Pancreas 5:626-629, 1990). A number of studies have been published in the meantime with differing results. The aims of our prospective multicentre study with members of the Arbeitsgemeinschaft leitender gastroenterologischer Krankenhausärzte (ALGK) were to assess whether obesity correlates with necrotizing pancreatitis, severe course of the disease, and mortality and to investigate whether adding obesity to the APACHE-II score improves the value of this prognostic score (C.D. Johnson et al., Pancreatology 4:1-6, 2004). Patients and methods: The study included 419 patients with acute pancreatitis (aetiology: biliary 50%, alcoholic 28%, other 8%, idiopathic 14%). All patients underwent contrast-enhanced computed tomography, scored according to Balthazar (BS), and were checked for early and late organ failure. A severe course of the disease was defined as need for artificial ventilation or dialysis or necrosis (BS >4) at any time during hospitalization, or death. Obesity was scored numerically according to body mass index: 0 = normal (BMI <26; 35% of the patients); 1 = overweight (BMI 2630; 36%); 2 = obese (BMI >30; 29%). Receiver-operating curves were calculated using admission APACHE-II and APACHE-0 scores Results: A high BMI was significantly associated with necrotizing pancreatitis (p=0.02), severe course (p=0.002) and death (p=0.03). When patients were split into the four aetiological categories, the correlation remained significant for patients with biliary pancreatitis (p=0.03-0.05). Adding obesity to the APACHE-II score slightly increased the predictive value of the score for necrotizing pancreatitis and severe course of the disease in patients with biliary acute pancreatitis (table1). Conclusion: Obesity is not only a risk factor for the development of local and systemic complications in acute pancreatitis but also increases the mortality of this disease. The APACHE-O score is slightly superior to the APACHE-II score in biliary acute pancreatitis only.
M1277 Quality of Life One Year After a Single Attack of Acute Pancreatitis B.W. Marcel Spanier, Marcel.G.W. Dijkgraaf, Marco Bruno Background: In 2003 a prospective cohort study of acute pancreatitis (AP) in the province of Northern Holland was initiated (EARL study). The disease spectrum of AP ranges from mild and self limiting (80-90%) to a rapidly progressive fulminate illness with morbidity rates up to 30-50%. Data regarding the burden of an attack of AP on quality of life (QoL) are very scarce. The aim of the present study is to investigate the QoL one year after a single attack of AP. Methods: Patients were included from 18 hospitals. Hospital records and nursing reports were reviewed to assess the severity of AP, etiological factors, hospital stay, complications and co-morbidity. QoL evaluations were performed one year after the attack of AP using the validated EORTC QLQ C-30 (3.0) questionnaire. Questionnaires returned
AGA Abstracts
A-374