M1278 Chronic Pancreatitis (CP) in the United States: Analysis of the National Ambulatory Medical Care Survey (NAMCS), 1993-2006

AGA Abstracts

The prevalence of low-trauma fracture in Chronic Pancreatitis is comparable to or higher than that of other “high risk” GI illnesses for which osteoporosis screening guidelines exist Odds Ratio of Low-Trauma Fracture

M1279 Smoking As a Co-Factor for Causation of Chronic Pancreatitis: A MetaAnalysis Angelo Andriulli, Edoardo Botteri, Piero Almasio, Generoso Uomo, Italo Vantini, Patrick Maisonneuve Objectives: Smoking causes a 75% increase in the risk of developing pancreatic carcinoma compared to non-smokers. However, data linking cigarette smoking to the development of chronic pancreatitis in alcoholics offer conflicting conclusions, so that only few pancreatic specialists advise alcoholics for smoking cessation treatment, besides alcohol abstinence. Our aim was to assess the evidence for tobacco smoking as a risk factor for the causation of chronic pancreatitis in alcoholics Methods: From a PubMed search spanning from 1966 to May 15, 2008 independent epidemiological studies were retrieved that contained information necessary to estimate the relative risk (RR) associated with tobacco smoking. When available, we used adjusted estimates. We performed a meta-analysis with random effects models to estimate pooled relative risks of chronic pancreatitis for current, former and ever smokers, in comparison to never smokers. We also performed dose-response, heterogeneity, publication bias, and sensitivity analyses. Results: Nine case-control studies and a single cohort study that evaluated, overall, 1068 patients with alcoholic chronic pancreatitis satisfied the inclusion criteria. When contrasted to never smokers, pooled risk estimates were 3.1 (95% CI 1.6-5.9) for ever smokers, 2.7 (95% CI 1.5-4.8) for current smokers, and 1.6 (9.5% CI 1.4-2.3) for former smokers. We found significant heterogeneity among the studies only for ever smokers (P = 0.044). Compared to never smokers, alcohol-adjusted estimates were 2.9 (95% CI 1.4-6.2) for ever smokers, 2.6 (95% CI 1-0-6.7) for current smoker, and 1.8 (95% CI 1.4-2.3) for former smokers. A dose-response effect of tobacco use on the risk was ascertained: the relative risk for subjects smoking <1 pack/day was 2.7 (95% CI 0.9-8.6), and increased to 3.7 (95% CI 1.2-11.1) in those smoking ≥1 pack/day. The risk diminished significantly after smoking cessation, as the relative risk estimate for former smokers dropped to a value of 1.6 (95% CI 1.1-2.3). Conclusion: Tobacco smoking may enhance the risk of developing chronic pancreatitis in alcoholics. Recommendation for smoking cessation, besides alcohol abstinence, should be incorporated in the management of alcoholic patients with or without chronic pancreatitis.

M1277 Under-Nutrition in Tropical Pancreatitis: Cause or Effect? Hariharan Regunath, Ganesh Pai Background: Under-nutrition is considered as a cause of Tropical pancreatitis (TP) since this disease is commonly seen in the under-privileged populations of the world. Objectives: To assess the anthropometric measurements (AM) in TP and alcoholic chronic pancreatitis (ACP) at presentation and compare the body mass index (BMI) with the pre-morbid values. To explore the relationship between nutritional status and features of the disease that might contribute to under-nutrition. Material and Methods: Anthropometric measurements were done in patients with TP and ACP aged >18 years at presentation and in matched healthy controls. Presence of pain, recent dietary restriction, diabetes mellitus (DM), calcification, and quantitative fecal elastase (FE) were assessed. Pre-morbid BMI was determined from recorded weight before illness. Patients were classified as alcoholic pancreatitis if intake of alcohol was > 40g/day for at least 5 years and tropical pancreatitis if no other cause was identified. Statistical comparison was done using SPSS 15.0. Results: Of the 44 (M:F = 40:4) included, 70% (n=31) had TP and the rest ACP. Patients with TP were younger than those with ACP (28.1 ± 10.2 yrs vs 41.7 ± 9.5 yrs, p <0.05), but were comparable for the presence of pain (100%), DM (29% vs 30.7%), calcification (58% vs 69%) and exocrine insufficiency (median FE = 53.02 vs 53.3 μg/gm). In the patients the BMI (19.1 ± 3.3 vs 24.7 ±1.4, p <0.01), triceps skin fold thickness (TSFT) (9.4 ± 3.9 vs 12.4 ±1.2 mm, p <0.01), mid arm circumference (MAC) (24.3 ± 3.5 vs 29.8 ± 4.5 cm, p <0.01) but not the waist-to-hip ratio (WHR) (0.9 ± 0.1 vs 0.9 ± 0.1, p >0.05) were significantly lower compared to controls. Under-nutrition (defined as BMI < 18.5 for Asians) was equally common in TP and ACP (15 (48.4%) vs 6 (46.1%), p >0.05). BMI (19.1 ± 3.6 vs 19 ± 2.5), TSFT (9.8 ± 4.1 vs 8.6 ± 3.3 mm), MAC (24.3 ± 3.6 vs 24.3 ± 3.3 cm) and WHR (0.9 ± 0.1 vs 0.9 ± 0.1, p >0.05) were similar in TP and ACP (p >0.05). The pre-morbid BMI was higher than the BMI at presentation (20.24 ± 3.81 vs 19.08 ± 3.26, p = 0.001). There was no association between the BMI and features contributing to under-nutrition (alcoholism, DM, recent dietary restriction, FE level and calcification) on univariate analysis. Conclusions: Under-nutrition in CP develops after the onset of illness, occurs equally commonly in TP and ACP and hence appears to be the effect rather than the cause of the former condition. The lack of correlation between under-nutrition and factors known to contribute to this might be due to the small numbers studied.

M1280 Prior Endoscopic Sphincterotomy Can Affect the Interpretation of SecretinStimulated Magnetic Resonance Cholangiopancreatography (S-MRCP) in Patients with Chronic Pancreatitis Ashish Chopra, Samer Alkaade, Frank R. Burton, Numan C. Balci Lack of pancreatic duct compliance and decreased duodenal filling on secretin-stimulated magnetic resonance cholangiopancreatography (S-MRCP) has been noted in patients with chronic pancreatitis. We previously described a statistically significant decrease in pancreatic duct dilation in response to secretin on S-MRCP between normal patients, with and without ES. The purpose of this study was to determine if pancreatic duct compliance and duodenal filling on S-MRCP in patients with chronic pancreatitis was different in those with and without ES, as well. Methods: A retrospective review of patients who were seen in our clinic from 12/06-5/08 was performed. Those patients who had evidence of chronic pancreatitis (abnormal endoscopic pancreatic function tests, and/or abnormal MRI and/or CT by Cambridge classification) and who underwent S-MRCP were studied. S-MRCP findings were analyzed, noting the change in pancreatic duct diameter from baseline to max dilation after secretin administration (0.2 mcg/kg IV dose of human secretin), the time to achieve max dilation, and the grade of duodenal filling at peak diameter. The mean for pancreatic duct diameter change, time to peak change, and duodenal filling were calculated. Results: Of the 37 patients studied, 15 had ES and 22 had intact sphincters of Oddi. In the sphincterotomy group, there was a mean change of 0.15mm of the pancreatic duct (range 0.1-0.27), while in the non-sphincterotomy group; the mean change was 0.58 mm (range 0.1-1.12) after secretin administration. The difference was significant with a P<0.005. From a previous study, we found that patients with a normal pancreas and an intact native sphincter (control group) had a mean change of 0.91 mm (range 0.31-1.97). Though there was a trend towards a longer time to maximal pancreatic duct dilation and lower duodenal filling at peak pancreatic duct diameter in those patients without ES, these results were not statistically significant. In addition, there was no difference in those patients who had only a biliary sphincterotomy compared to those with both biliary and pancreatic sphincterotomies. Conclusion: Endoscopic sphincterotomy significantly decreases pancreatic duct dilation in response to secretin on S-MRCP in patients with chronic pancreatitis. However, further studies are required to determine the effect sphincterotomy has on the amount of duodenal filling and the rate at which duodenal filling occurs. As S-MRCP is becoming increasingly utilized for documenting chronic pancreatitis, one must be aware of the absence of a functional pancreatic sphincter (s/p sphincterotomy),to avoid misinterpretation of pancreatic duct compliance.

M1278 Chronic Pancreatitis (CP) in the United States: Analysis of the National Ambulatory Medical Care Survey (NAMCS), 1993-2006 Darwin Conwell, Bechien Wu, Peter A. Banks Outpatient data describing CP demographics, healthcare utilization and disease burden is lacking. The NAMCS is a national probability-based sample survey of ambulatory office visits in the United States that can provide epidemiologic data. STUDY AIMS: To obtain national estimates for patient 1) demographics, 2) healthcare utilization and 3) prevalence of modifiable factors associated with CP disease. METHODS: The National Center for Health Statistics division of the Center for Disease Control conducts the NAMCS healthcare survey on an annual basis. We analyzed data from the NAMCS survey from years 1993-2006. Cases of CP were identified based on ICD-9-CM code (577.1). Statistical analysis: SAS version 9.1 (Cary, NC) PROC SURVEY procedures utilized to incorporate weighting factors from complex survey design. RESULTS: There were an estimated 1.6 million ambulatory visits for CP in the United States. 1. Patient demographic information: There was on average 116,000 annual office visits during the study period. 67% of patients were female gender. Race/Ethnicity: 87% white, 9% black, and 5% other. Reason for visit: 57% pain (abdominal, biliary or back pain), 6% nutritional and 37% other. Office Setting: 41% IM, 29% GI, 24% FP and 2% Surg. U.S. Regional Distribution: 14% from northeast, 16% south, 42% midwest, and 28% from the west. 2. Healthcare utilization data: Average number of visits in past 12 months: 5% none, 29% (1-2), 12% (3-4), 29% (>6)and 25% other. Medications prescribed: 22% pancreatic enzyme, 14% narcotics, 19% proton-pump inhibitors, 11% anti-emetics and 8% anti-depressants. Imaging studies: CT, Ultrasound, or MRI in 81% of patients. Payment source (19952006): 28% medicare, 15% medicaid, 44% private insurance, 8% self-pay and 5% other. 3. Modifiable associated factors: 42% of respondents were current smokers and 19% reported depression. CONCLUSIONS: 1. NAMCS national survey data can be used to determine the healthcare burden and economic impact of CP in the United States. 2. Statistical Analysis of the NAMCS probability-based survey reveals that CP patients are: a) predominantly female, b) frequently visit primary care providers for evaluation of pain, c) are infrequently prescribed pancreatic enzymes, narcotic analgesics, and anti-depressants; and d) undergoe a large number of imaging studies. 3. Future studies should consider targeting modifiable factors such as smoking and depression in hopes of retarding chronic pancreatic disease progression. 4. National survey data can be used to determine Sample size and focus the Study Aims of prospective clinical trials in CP.

AGA Abstracts

M1281 Evaluation of a New Endoscopic Pancreatic Function Test (ePFT) Technique Using Combined Secretin and Cholecystokinin (CCK) Stimulation Ryan Law, Tyler Stevens, Mansour A. Parsi Background: Current ePFT methods use either secretin (S-ePFT) or CCK (C-ePFT). The SePFT measures duct-cell function; the C-ePFT measures acinar-cell function. A comprehensive ePFT using both hormones (S-C ePFT) has not been studied. Aim: Determine normal lipase and bicarb concentrations for a S-C ePFT, and compare with prior studies using single hormone stimulation. Methods: Healthy adults underwent sedated endoscopy (non-smokers, minimal alcohol). Hormone consisted of secretin (0.2mcg/kg IV bolus) and CCK (40ng/kg/ h IV infusion). Duodenal fluid was suctioned continuously in 5-min samples from 25 to 50 min after hormone stimulation. Samples were analyzed for lipase and bicarb concentration. Results were compared with past studies of the S-ePFT and C-ePFT in healthy subjects. Results: 10 subjects underwent the S-C ePFT (5M/5F, mean age 36 yrs). The mean peak

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