- Email: [email protected]
M1393 Endoscopic Ultrasound-Guided Trucut Biopsy (EUS TCB) Diagnosis of Autoimmune Pancreatitis (AIP)
(CFA m= 84.1%) than the low dose (CFA m=81.1%). For subjects with a baseline CFA<65%, the increase was +36.8% (high dose) and +27.2% (low dose). Significant increases compared to baseline were observed in CNA (low: +5.3; high: +7.6; p<0.001) and mean body weight (low: +0.4; high: +0.5; p≤0.021) with both doses of ZENPEP. Percentage of days with clinical symptoms of EPI was lower with ZENPEP versus baseline. ZENPEP was safe and well tolerated with GI complaints being the most frequently reported adverse events. Conclusions: ZENPEP is a novel enteric coated stable porcine-derived pancreatic enzyme replacement preparation with no overage. This study provides data on the benefit of ZENPEP across the spectrum of disease severity in EPI due to CP. ZENPEP, both low dose and high dose, was effective and safe in improving fat and protein absorption in adult CP patients with EPI. Maldigestion symptoms and body weight also improved.
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Since a normal pancreatic secretion is not required for iron absorption, iron metabolism and iron-deficiency anemia has not been studied in the context of pancreatic diseases. Cephalic duodenopancreatectomy (CDP) is a frequent surgical procedure for patients with chronic pancreatitis (CP) and pancreatic cancer. Iron absorption may be impaired in patients after CDP because of a reduced gastric acid secretion and loss of intestinal absorption surface. Aim of the present study was to evaluate iron metabolism and frequency of iron-deficiency anemia in patients after CDP due to CP, compared to non-operated CP patients with and without exocrine pancreatic insufficiency (EPI). Methods: Retrospective analysis of a prospectively collected data base of patients diagnosed of CP in our Pancreas Unit over the last 3 years. Exocrine pancreatic function was evaluated in every patient after diagnosis by means of the optimized 13C-mixed triglyceride breath test. Patients were classified according to previous CDP and presence of EPI. Hemoglobin, mean corpuscular volume (MCV) and iron levels were quantified at diagnosis. Data are shown as mean and 95% confidence interval (CI), or percentage. Statistical analysis was performed by ANOVA and Bonferroni test, and chi-square test. Factors (age, gender, etiology, years of disease, EPI, CDP) potentially related to the presence of anemia were evaluated by multivariate stepwise unconditional logistic regression analysis. Results: 239 patients were included (mean age 50 years, range 8-82 years, 199 male). 20 patients (8.4%) had previously undergone a CDP. Among non-operated patients, 74 (30.9%) had EPI, and 145 (60.7%) had no EPI. Anemia was present in 9 (45%) CDP patients, 14 (18.9%) EPI patients, and 16 (11%) patients without EPI (p=0.016). As expected, hemoglobin levels were significantly lower in CDP patients (12.8 g/dL; 95%CI: 12.1-13.7) than in non-operated patients (13.9 g/dL, 95%CI: 13.5-14.5 g/dL in patients with EPI and 14.4 g/dL, 95%CI: 14.1-14.4 g/dL in patients without EPI) (p=0.001). MCV was similar in the three groups of patients. Iron deficiency was present in 7 (35%) CDP patients, compared to 7 (9.5%) patients with EPI and 19 (13%) patients without EPI (p= 0.07), and serum iron levels were significantly lower in DPC patients than in non-operated patients (p<0.05). CDP was the only variable independently associated to anemia (OR 5.04, 95%CI 1.87-13.58, p<0.001) and iron-deficiency (OR 2.43, 95%CI 0.82-7.15, p=0.051) in patients with chronic pancreatitis. Conclusion: The presence of anemia is not infrequent in patients with chronic pancreatitis. CDP is the main cause of iron-deficient anemia in these patients.
M1389 Chronic Pancreatitis: Morphologic Differences at Disease Onset Between Pediatric and Adult Patients Federico Iacopini, Massimiliano Mutignani, Vincenzo Perri, Pietro Familiari, Andrea Tringali, Guido Costamagna BACKGROUND and AIM. Chronic pancreatitis (CP) may develop in pediatric and adult subjects, but differences between these two groups are not reported. METHODS. Retrospective single center study. All the 39 pediatric CP patients (median age 12 yrs, range 2.5-18) actively followed up were compared to 80 consecutive CP adult patients (median age 50 yrs, range 32-84). Diagnosis of CP was made according to recurrent clinical symptoms, enzymes elevation, presence of CP morphologic changes. The CP stage was assessed after review of the first ERCP images according to the Cremer's classification of the main pancreatic duct (MPD) morphology: normal MPD with secondary ducts dilations (CP1); MPD with multiple non critical strictures (CP3); MPD with a single critical stricture or with an almost occluding stone (CP4). Chronic pseudocysts, proteinous plugs, calcific stones, and CPrelated common bile duct (CBD) strictures were also assessed. RESULTS. Prevalence of females was significantly higher in the pediatric population: 51% vs. 26% (P=0.012). The median time interval between clinical onset of CP and the first ERCP was 2 years, with no differences between the two groups. Prevalence of either a pancreas divisum or a Santorini dominant anatomy was higher in the pediatric population (33% vs. 21%), but not significantly. Pediatric CP patients showed significantly less severe CP stages, lower prevalence of pseudocysts, plugs and calcific stones, and CP-related CBD strictures than the adult population (see Table). CONCLUSIONS. Although a similar time interval between clinical onset of CP and morphologic assessment of MPD morphology was found in both the pediatric and adult populations, CP in the pediatric population have significantly less advanced morphological alterations both of the MPD and pancreatic parenchyma. Analysis of gene mutations and stratification of patients according to the exposure to noxious agents is necessary to identify the causes of these morphological differences.
M1392 Re-Evaluation of Pancreatic Type of SOD and Idiopathic Chronic Pancreatitis Naoteru Miyata, Shigenari Hozawa, Hajime Higuchi, Yuji Nakamura, Yoshiyuki Yamagishi, Toshifumi Hibi Background and Aim: Pancreatic SOD has been reported to cause idiopathic recurrent pancreatitis and post-ERCP pancreatitis. Patients who complain of continuous upper abdominal pain and show occasional elevation of serum pancreatic enzymes are sometimes observed as suspected cases of chronic pancreatitis without any effective treatment. Sphincter of Oddi Dysfunction (SOD) describes SO dysmotility or stenosis leading to reduced transphincteric flow of bile or pancreatic juice. Type II of pancreatic SOD by the criteria of Milwaukee Classification proposed by Hogan and Geenen may be involved in the above cases. Since the treatment of SOD such as endoscopic sphincterotomy (EST) as well as pharmacological treatment is different from that of chronic pancreatitis, it is important to differentiate the pancreatic type SOD from chronic pancreatitis suspected cases. The aim of this study is to differentiate the pancreatic SOD from potentially diagnosed chronic pancreatitis and to reevaluate the indication of EST. Methods: For four years from May 2005 to November 2009, 12 cases of idiopathic chronic pancreatitis suspected cases were performed ERCP and sphincter of Oddi manometry (SOM) in order to diagnose SOD. SOM was performed by canulating the ampulla with the manometry catheter into both biliary and pancreatic duct. EST was performed in the case of type I and type II of pancreatic type SOD. In the case of type III pancreatic SOD pancreatic stents were inserted without EST. Results and Discussion: The percentage of patients who diagnosed as pancreatic SOD in suspected cases of chronic pancreatitis were 41%(5/12) and they were all female. All cases were diagnosed as type II of pancreatic type SOD and were received minor incision of EST. After EST, none of the cases has shown abnormality of serum pancreatic enzymes or clinical symptoms (period of observation:3.2±0.8 years). Endoscopic treatment by EST showed a beneficial effect on the relief of clinical symptoms in type II of pancreatic SOD, which has been suffered from abdominal pain for a long time. Conclusion: It is suggested that SOM may be recommend to be done in the suggested case of chronic pancreatitis in order to discriminate pancreatic SOD.
M1390 Prevalence of Depression Among Patients With Alcoholic Pancreatitis Anne-Marie Marion-Audibert, Vinciane Rebours, Laurent Heyries, Olivier Lejeune, Arnaud Boruchowicz, Barbara Bournet, Marc Barthet, Louis Buscail, Philippe Levy, Philippe B. Ruszniewski, Pascal Hammel, Jean Christophe Souquet The aim of the study was to assess prevalence of depression among patients with CP and to compare this figure with the prevalence of depression in patients with alcoholic cirrhosis (AC) and in heavy drinkers patients without chronic pancreatitis or cirrhosis (HD). Consecutive patients with CP, AC or HD were prospectively included between september 07 and june 09 in a French multicenter study. Depression was assessed using CIM-10 evaluation. Epidemiological and risk factors were systematically reported in the database. Of the 344 patients included, there were 150 CP, 102 AC and 92 HD patients. Mean age were 50 (2575), 59 (36-83) and 44 (23-74) respectively for the 3 groups. Current alcohol consumption was present in similar in the CP and AC groups (39%) and more elevated in the HD patients (72%). Past or current smokers were observed respectively in 91%, 64% and 89% respectively. Mean pain score measured with the visual analogue scale was 2.4 in (0-10) in CP patients (of whom 43 were treated with morphine), 0.5 (0-5) in AC patients (of whom 8 received morphine) and 0.7 (0-7) in HD group (non received morphine at the time of the study). Diabetes was present in 28% (type I: 16%), 24% (type I: 11%) and 8% (type I: 4%) respectively in the CP, AC and HD groups. Among non-retired patients, only 41% were working at full- or halftime. The figure was 43% in AC subjects and 51% in HD ones. Invalidity related to the causal disease was higher in AC patients (41%) in comparison with CP (33%) or HD (6%) patients. Finally patients have been previously treated for depression in 29%, 14% and 39% of cases of CP, AC and HD groups. Treatment for depression at the time of the study was given in respectively 18%, 7% and 17%. Using the CIM-10 evaluation, prevalence of depression was was much higher 46 % (n=69), 24,5 % (n=25) and 46,7% (n=43) respectively in CP, AC and HD groups (p<0.05). Thus in the present series, prevalence of depression was significantly higher in patients with CP than compared with AC patients. Depression was undertreated in all 3 groups. In CP patients, pain, tobacco, past history of depression, invalidity or unemployement were potential risk factors of depression.
M1393 Endoscopic Ultrasound-Guided Trucut Biopsy (EUS TCB) Diagnosis of Autoimmune Pancreatitis (AIP) Michael J. Levy, Thomas C. Smyrk, Naoki Takahashi, Lizhi Zhang, Jonathan E. Clain, Michael B. Farnell, Ferga C. Gleeson, Michael L. Kendrick, Randall K. Pearson, Bret T. Petersen, Elizabeth Rajan, Mark D. Topazian, Santhi Swaroop Vege, Kenneth K. Wang, Maurits J. Wiersema, Suresh T. Chari Background/Aims: The presence of typical pancreatic histology allows definitive diagnosis of AIP. As per recent expert panel deliberations on AIP held at the 2009 Honolulu (APA, JPS) Meeting, pancreatic fine needle aspiration (FNA) is inadequate for diagnosis of AIP. There was consensus that for definitive histologic diagnosis of AIP larger pancreatic specimens obtained by core biopsy (at surgery or by EUS TCB) are necessary. However, some discouraged the use of EUS TCB due to the perceived insufficient sensitivity for diagnosis of AIP and the associated risk. In a large cohort of AIP we determined the diagnostic sensitivity and safety of EUS TCB. Methods: From a prospectively maintained database of all patients with AIP diagnosed by HISORt criteria (n=100), we identified 48 AIP patients who had undergone
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Iron Metabolism and Iron-Deficiency Anemia in Patients With Chronic Pancreatitis Enrique Dominguez-Munoz, Margarita Castineira, Jose Larino-Noia, Maria Luaces, Julio Iglesias-Garcia
AGA Abstracts
pancreatic EUS TCB with or without additional FNA (n=37) by 5 endosonographers in our group. All specimens were interpreted by dedicated GI pathologists blinded to the clinical data. All complications were prospectively tracked and logged in the database. Results: AIP patients undergoing EUS TCB (38 male, 10 female; mean age 59.7 years (range 18-87)) had a mean of 2.9 TCBs (range 1-7) per patient. AIP was histologically diagnosed on EUS TCB in 35 (73%) patients; the diagnostic sensitivity varied among the 5 endosonographers from 33% to 90%. Non-diagnostic cases were found to have chronic pancreatitis (n=8), nonspecific histology (n=2), and failed tissue acquisition (n=3). EUS FNA (mean 3.4 passes, range 1-7 passes) failed to establish or suggest the diagnosis in any patient (n=37). Complications of EUS TCB included mild transient abdominal pain (n=3) and self-limited intraprocedural bleeding (n=1). No patient required hospitalization or therapeutic intervention. The diagnosis of AIP was strongly suspected prior to EUS in 14 patients as a result of their clinical, laboratory, and imaging findings. For 22 patients the diagnosis was considered preEUS as part of a broader differential, and in 12 patients the EUS appearance alone led to the initial suspicion of AIP. Serum IgG4 was ≥1x ULN in 42%, and ≥2xULN in only 23% of patients. None of the patients with EUS TCB diagnosis of AIP underwent surgery. In the patients with false negative EUS TCB, diagnosis was made by HISORt criteria. Over a mean follow-up of 2.6 years no false negative diagnoses of pancreatic cancer were identified. Conclusions: In a large cohort with AIP undergoing EUS TCB we show that pancreatic biopsy is safe and provides sufficient material to definitively diagnose AIP with high sensitivity. EUS TCB obviates the need for surgical intervention in this medically treatable disease.
M1396 Autoimmune Chronic Pancreatitis in Children Grzegorz Oracz, Bozena Cukrowska, Jaroslaw Kierkus, Maciej Dadalski, Jozef Ryzko, Jerzy Socha Background: In the last decade we can observe gradual increase of autoimmune diseases. The reported paediatric experience with chronic pancreatitis (CP) is small and little is known about the role of autoimmune chronic pancreatitis (AICP). Aim: The aim of the study was to assess the frequency of autoimmune markers in children with CP. Patients and Methods: During 2000 to 2009, we hospitalized 62 children with CP (33 boys and 29 girls; age 2.818 years, mean age: 11.9 years). Clinical data were recorded and analyzed. Gammaglobulins, IgG4, autoantibodies (ANA, ASMA, AMA, APCA, LKM and AHA) were measured in all children. Results: Autoimmune disease was present in 5 patients (8%): ulcerative colitis in 2 patients, PSC, dermatomiositis and panniculitis in 1 patient each. Hypergammaglobulinemia (>16g/l) was present in 10 cases. An increase of IgG4 level was present in 4 children. Autoantibodies were present in 34 children (54.8%). ANAs (>1/80e) were present in 16 patients with CP (in 6 pts >1/640e). ASMAs (>1/80e) were present in 16 children. APCAs, AMAs, AHAs and LKM were absent in all patients. Combining clinical and biochemical autoimmune parameters, 37 patients (59.7%) had at least 1 autoimmune marker of the disease. In 17 patients (27.4%) with CP and autoimmune stigmata other known causative factors of CP were present. In 14 patients we found gene mutations predisposing to CP. There was no difference in the severity of the disease and clinical course between children with autoimmune stigmata and patients without autoimmune markers. Conclusions: In children with CP, similarly to adults, there is a high frequency of clinical and biochemical markers of autoimmunity. Number of CP with autoimmune origin in children is greatly underreported.
M1394 How Common is Crohn's Pancreatitis? A 14 Year Autopsy Review Rukshana Cader, Anthony N. Kalloo, Theodore M. Bayless, Samuel A. Giday Background: In adults with Crohn's disease (CD) acute pancreatitis has been observed usually as a consequence of medications, gallstones and alcohol. A significant percentage of patients though have no known cause and the frequency of Crohn's pancreatitis is not clearly known. Aim: To estimate the frequency of Crohn's induced pancreatitis in patients with CD who had autopsies over a period of 14 years. Methods: Our prospective pathology autopsy database was queried for Crohn's disease patients that were evaluated and/or treated at Johns Hopkins Hospital from 1995 -2009. Relevant demographic, clinical, surgical, and radiographic data were recorded in those patients with evidence of pancreatitis. Results: 37 patients with CD had autopsies performed during the study period. Of these seven patients (19%) were found to have pancreatitis on histopathologic evaluation. Acute pancreatitis, manifested as neutrophilic inflammatory infiltrates and interstitial edema were seen in two patients. Mixed acute and chronic inflammation was seen in 2 more patients while the remaining three had findings consistent with chronic pancreatitis. Majority of the patients (86%) were on 5ASA drug and 6MP. The one patient who was not on any medication had evidence of gallstones. All patients with evidence of acute inflammation in the pancreas presented clinically with acute pancreatitis. The remaining 5 (71%) had no clinical history of pancreatitis but had evidence of chronic pancreatitis on histological evaluation. None of these patients had pancreatic granulomatous inflammation on histopathologic evaluation despite being present elsewhere in the GI tract. Conclusion: In this 14 year autopsy series, 19% of patients with Crohn's disease had evidence of pancreatitis. All the patients with evidence of chronic pancreatitis on histology had no clinical history of chronic or acute pancreatitis. The classic granulomatous inflammation of CDs was not present in any of our patients.
M1397 Epidemiological Study of Pancreatic Diabetes in Japan: A Nationwide Study Tetsuhide Ito, Makoto Otsuki, Hisato Igarashi, Taichi Nakamura, Nao Fujimori, Takamasa Oono, Ryoichi Takayanagi, Tooru Shimosegawa Objectives: There have been few epidemiological studies on pancreatic diabetes. In this study we determined the incidence and pathology of pancreatic diabetes in Japan. Methods: We examined the epidemiology of pancreatic diabetes in Japan in 2005 by using a nationwide stratified random sampling method. Especially, we focused on newly developed diabetes in association with the occurrence of pancreatic disease (true pancreatic diabetes). Results: A total of 19,500 individuals received treatment for true pancreatic diabetes, accounting for 0.8% of patients with diabetes. Prevalence was estimated to be 15.2/100,000 with an annual onset incidence of 1.1/100,000. With regard to the complications in true pancreatic diabetes, the incidence of retinopathy was lower than that in type 1 and 2 diabetes. Among true pancreatic diabetes with chronic pancreatitis, alcoholic pancreatitis was found in the largest sector. Furthermore as many as 53.7% were continuous drinkers, and 66.7% received insulin therapy. The frequency of hypoglycemia was high in regular drinkers treated with insulin. Hypoglycemia was a major cause of death in patients who were on insulin and continuous drinkers. Conclusion: We clarified the epidemiology of pancreatic diabetes in Japan. Patients with chronic pancreatitis-associated pancreatic diabetes should receive lifestyle guidance focused on drinking cessation. Epidemiology of pancreatic diabetes in Japan (2005)
M1395 Treatment With Liprotamase Maintains Nutritional Parameters in Subjects With Chronic Pancreatitis or Total Pancreatectomy and Exocrine Pancreatic Insufficiency Alphonso Brown, Chris Stevens, Donna S. Cohen, Marilyn Campion, Steven D. Freedman Background and Aims: Liprotamase is a novel non-porcine pancreatic enzyme replacement therapy (PERT) containing 3 highly purified microbial-derived enzymes: crystalline protease, amylase, and crystalline, cross-linked, recombinant lipase. The efficacy and safety of this PERT has been demonstrated in two well-controlled short-term studies. A one year openlabel trial was performed to study the long-term safety and tolerability of liprotamase in subjects with chronic pancreatitis (CP) or total pancreatectomy (TP) with exocrine pancreatic insufficiency (EPI). This trial also measured long-term outcomes (nutritional parameters) such as weight, and BMI. The study was terminated by the Sponsor for corporate reasons with 26 subjects completing 4 months of treatment, 14 completing at least six months and 4 completing the full 12 months of therapy. Methods: This was a 12 month open-label study in subjects with CP/TP and EPI. Subjects were ≥ 18 years of age, met criteria for CP or had undergone TP, were clinically stable, and had either clinical features of EPI or a fecal elastase < 100 μg/g. Subjects took one capsule of liprotamase (containing 32,500 units lipase activity, 25,000 units protease activity and 3,750 units amylase activity) in the middle of 3 meals and 2 snacks each day. Subjects were allowed to increase to 2 capsules per meal. Safety measures included incidence and severity of adverse events and laboratory parameters. Results: After obtaining informed consent, 39 subjects were enrolled and treated. The average number of capsules per day was 4.1 for all subjects. Liprotamase was well tolerated and there were no obvious safety signals. Nutrition was assessed by repeated measures of weight and BMI. Median weight at Baseline was 63.5 kg (n=39), 64.1 kg at month 4 (n=26), and 64.6 kg at month 6 (n=14). Median BMI was 22.2 kg/m2 at Baseline (n=39), 21.9 kg/m2 at month 4 (n=26) and 21.8 kg/m2 at month 6 (n=14). No meaningful differences in weight or BMI were observed when investigating the subgroups of drug exposure or use of acid suppression. Conclusions: The results of this study indicate that daily treatment with liprotamase resulted in the long term maintenance of nutrition as measured by weight and BMI in subjects with CP and TP. This study was supported by Alnara Pharmaceuticals Inc.
AGA Abstracts
Prevalence of diabetic complications in true pancreatic diabetes.
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Since a normal pancreatic secretion is not required for iron absorption, iron metabolism and iron-deficiency anemia has not been studied in the context of pancreatic diseases. Cephalic duodenopancreatectomy (CDP) is a frequent surgical procedure for patients with chronic pancreatitis (CP) and pancreatic cancer. Iron absorption may be impaired in patients after CDP because of a reduced gastric acid secretion and loss of intestinal absorption surface. Aim of the present study was to evaluate iron metabolism and frequency of iron-deficiency anemia in patients after CDP due to CP, compared to non-operated CP patients with and without exocrine pancreatic insufficiency (EPI). Methods: Retrospective analysis of a prospectively collected data base of patients diagnosed of CP in our Pancreas Unit over the last 3 years. Exocrine pancreatic function was evaluated in every patient after diagnosis by means of the optimized 13C-mixed triglyceride breath test. Patients were classified according to previous CDP and presence of EPI. Hemoglobin, mean corpuscular volume (MCV) and iron levels were quantified at diagnosis. Data are shown as mean and 95% confidence interval (CI), or percentage. Statistical analysis was performed by ANOVA and Bonferroni test, and chi-square test. Factors (age, gender, etiology, years of disease, EPI, CDP) potentially related to the presence of anemia were evaluated by multivariate stepwise unconditional logistic regression analysis. Results: 239 patients were included (mean age 50 years, range 8-82 years, 199 male). 20 patients (8.4%) had previously undergone a CDP. Among non-operated patients, 74 (30.9%) had EPI, and 145 (60.7%) had no EPI. Anemia was present in 9 (45%) CDP patients, 14 (18.9%) EPI patients, and 16 (11%) patients without EPI (p=0.016). As expected, hemoglobin levels were significantly lower in CDP patients (12.8 g/dL; 95%CI: 12.1-13.7) than in non-operated patients (13.9 g/dL, 95%CI: 13.5-14.5 g/dL in patients with EPI and 14.4 g/dL, 95%CI: 14.1-14.4 g/dL in patients without EPI) (p=0.001). MCV was similar in the three groups of patients. Iron deficiency was present in 7 (35%) CDP patients, compared to 7 (9.5%) patients with EPI and 19 (13%) patients without EPI (p= 0.07), and serum iron levels were significantly lower in DPC patients than in non-operated patients (p<0.05). CDP was the only variable independently associated to anemia (OR 5.04, 95%CI 1.87-13.58, p<0.001) and iron-deficiency (OR 2.43, 95%CI 0.82-7.15, p=0.051) in patients with chronic pancreatitis. Conclusion: The presence of anemia is not infrequent in patients with chronic pancreatitis. CDP is the main cause of iron-deficient anemia in these patients.
M1389 Chronic Pancreatitis: Morphologic Differences at Disease Onset Between Pediatric and Adult Patients Federico Iacopini, Massimiliano Mutignani, Vincenzo Perri, Pietro Familiari, Andrea Tringali, Guido Costamagna BACKGROUND and AIM. Chronic pancreatitis (CP) may develop in pediatric and adult subjects, but differences between these two groups are not reported. METHODS. Retrospective single center study. All the 39 pediatric CP patients (median age 12 yrs, range 2.5-18) actively followed up were compared to 80 consecutive CP adult patients (median age 50 yrs, range 32-84). Diagnosis of CP was made according to recurrent clinical symptoms, enzymes elevation, presence of CP morphologic changes. The CP stage was assessed after review of the first ERCP images according to the Cremer's classification of the main pancreatic duct (MPD) morphology: normal MPD with secondary ducts dilations (CP1); MPD with multiple non critical strictures (CP3); MPD with a single critical stricture or with an almost occluding stone (CP4). Chronic pseudocysts, proteinous plugs, calcific stones, and CPrelated common bile duct (CBD) strictures were also assessed. RESULTS. Prevalence of females was significantly higher in the pediatric population: 51% vs. 26% (P=0.012). The median time interval between clinical onset of CP and the first ERCP was 2 years, with no differences between the two groups. Prevalence of either a pancreas divisum or a Santorini dominant anatomy was higher in the pediatric population (33% vs. 21%), but not significantly. Pediatric CP patients showed significantly less severe CP stages, lower prevalence of pseudocysts, plugs and calcific stones, and CP-related CBD strictures than the adult population (see Table). CONCLUSIONS. Although a similar time interval between clinical onset of CP and morphologic assessment of MPD morphology was found in both the pediatric and adult populations, CP in the pediatric population have significantly less advanced morphological alterations both of the MPD and pancreatic parenchyma. Analysis of gene mutations and stratification of patients according to the exposure to noxious agents is necessary to identify the causes of these morphological differences.
M1392 Re-Evaluation of Pancreatic Type of SOD and Idiopathic Chronic Pancreatitis Naoteru Miyata, Shigenari Hozawa, Hajime Higuchi, Yuji Nakamura, Yoshiyuki Yamagishi, Toshifumi Hibi Background and Aim: Pancreatic SOD has been reported to cause idiopathic recurrent pancreatitis and post-ERCP pancreatitis. Patients who complain of continuous upper abdominal pain and show occasional elevation of serum pancreatic enzymes are sometimes observed as suspected cases of chronic pancreatitis without any effective treatment. Sphincter of Oddi Dysfunction (SOD) describes SO dysmotility or stenosis leading to reduced transphincteric flow of bile or pancreatic juice. Type II of pancreatic SOD by the criteria of Milwaukee Classification proposed by Hogan and Geenen may be involved in the above cases. Since the treatment of SOD such as endoscopic sphincterotomy (EST) as well as pharmacological treatment is different from that of chronic pancreatitis, it is important to differentiate the pancreatic type SOD from chronic pancreatitis suspected cases. The aim of this study is to differentiate the pancreatic SOD from potentially diagnosed chronic pancreatitis and to reevaluate the indication of EST. Methods: For four years from May 2005 to November 2009, 12 cases of idiopathic chronic pancreatitis suspected cases were performed ERCP and sphincter of Oddi manometry (SOM) in order to diagnose SOD. SOM was performed by canulating the ampulla with the manometry catheter into both biliary and pancreatic duct. EST was performed in the case of type I and type II of pancreatic type SOD. In the case of type III pancreatic SOD pancreatic stents were inserted without EST. Results and Discussion: The percentage of patients who diagnosed as pancreatic SOD in suspected cases of chronic pancreatitis were 41%(5/12) and they were all female. All cases were diagnosed as type II of pancreatic type SOD and were received minor incision of EST. After EST, none of the cases has shown abnormality of serum pancreatic enzymes or clinical symptoms (period of observation:3.2±0.8 years). Endoscopic treatment by EST showed a beneficial effect on the relief of clinical symptoms in type II of pancreatic SOD, which has been suffered from abdominal pain for a long time. Conclusion: It is suggested that SOM may be recommend to be done in the suggested case of chronic pancreatitis in order to discriminate pancreatic SOD.
M1390 Prevalence of Depression Among Patients With Alcoholic Pancreatitis Anne-Marie Marion-Audibert, Vinciane Rebours, Laurent Heyries, Olivier Lejeune, Arnaud Boruchowicz, Barbara Bournet, Marc Barthet, Louis Buscail, Philippe Levy, Philippe B. Ruszniewski, Pascal Hammel, Jean Christophe Souquet The aim of the study was to assess prevalence of depression among patients with CP and to compare this figure with the prevalence of depression in patients with alcoholic cirrhosis (AC) and in heavy drinkers patients without chronic pancreatitis or cirrhosis (HD). Consecutive patients with CP, AC or HD were prospectively included between september 07 and june 09 in a French multicenter study. Depression was assessed using CIM-10 evaluation. Epidemiological and risk factors were systematically reported in the database. Of the 344 patients included, there were 150 CP, 102 AC and 92 HD patients. Mean age were 50 (2575), 59 (36-83) and 44 (23-74) respectively for the 3 groups. Current alcohol consumption was present in similar in the CP and AC groups (39%) and more elevated in the HD patients (72%). Past or current smokers were observed respectively in 91%, 64% and 89% respectively. Mean pain score measured with the visual analogue scale was 2.4 in (0-10) in CP patients (of whom 43 were treated with morphine), 0.5 (0-5) in AC patients (of whom 8 received morphine) and 0.7 (0-7) in HD group (non received morphine at the time of the study). Diabetes was present in 28% (type I: 16%), 24% (type I: 11%) and 8% (type I: 4%) respectively in the CP, AC and HD groups. Among non-retired patients, only 41% were working at full- or halftime. The figure was 43% in AC subjects and 51% in HD ones. Invalidity related to the causal disease was higher in AC patients (41%) in comparison with CP (33%) or HD (6%) patients. Finally patients have been previously treated for depression in 29%, 14% and 39% of cases of CP, AC and HD groups. Treatment for depression at the time of the study was given in respectively 18%, 7% and 17%. Using the CIM-10 evaluation, prevalence of depression was was much higher 46 % (n=69), 24,5 % (n=25) and 46,7% (n=43) respectively in CP, AC and HD groups (p<0.05). Thus in the present series, prevalence of depression was significantly higher in patients with CP than compared with AC patients. Depression was undertreated in all 3 groups. In CP patients, pain, tobacco, past history of depression, invalidity or unemployement were potential risk factors of depression.
M1393 Endoscopic Ultrasound-Guided Trucut Biopsy (EUS TCB) Diagnosis of Autoimmune Pancreatitis (AIP) Michael J. Levy, Thomas C. Smyrk, Naoki Takahashi, Lizhi Zhang, Jonathan E. Clain, Michael B. Farnell, Ferga C. Gleeson, Michael L. Kendrick, Randall K. Pearson, Bret T. Petersen, Elizabeth Rajan, Mark D. Topazian, Santhi Swaroop Vege, Kenneth K. Wang, Maurits J. Wiersema, Suresh T. Chari Background/Aims: The presence of typical pancreatic histology allows definitive diagnosis of AIP. As per recent expert panel deliberations on AIP held at the 2009 Honolulu (APA, JPS) Meeting, pancreatic fine needle aspiration (FNA) is inadequate for diagnosis of AIP. There was consensus that for definitive histologic diagnosis of AIP larger pancreatic specimens obtained by core biopsy (at surgery or by EUS TCB) are necessary. However, some discouraged the use of EUS TCB due to the perceived insufficient sensitivity for diagnosis of AIP and the associated risk. In a large cohort of AIP we determined the diagnostic sensitivity and safety of EUS TCB. Methods: From a prospectively maintained database of all patients with AIP diagnosed by HISORt criteria (n=100), we identified 48 AIP patients who had undergone
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Iron Metabolism and Iron-Deficiency Anemia in Patients With Chronic Pancreatitis Enrique Dominguez-Munoz, Margarita Castineira, Jose Larino-Noia, Maria Luaces, Julio Iglesias-Garcia
AGA Abstracts
pancreatic EUS TCB with or without additional FNA (n=37) by 5 endosonographers in our group. All specimens were interpreted by dedicated GI pathologists blinded to the clinical data. All complications were prospectively tracked and logged in the database. Results: AIP patients undergoing EUS TCB (38 male, 10 female; mean age 59.7 years (range 18-87)) had a mean of 2.9 TCBs (range 1-7) per patient. AIP was histologically diagnosed on EUS TCB in 35 (73%) patients; the diagnostic sensitivity varied among the 5 endosonographers from 33% to 90%. Non-diagnostic cases were found to have chronic pancreatitis (n=8), nonspecific histology (n=2), and failed tissue acquisition (n=3). EUS FNA (mean 3.4 passes, range 1-7 passes) failed to establish or suggest the diagnosis in any patient (n=37). Complications of EUS TCB included mild transient abdominal pain (n=3) and self-limited intraprocedural bleeding (n=1). No patient required hospitalization or therapeutic intervention. The diagnosis of AIP was strongly suspected prior to EUS in 14 patients as a result of their clinical, laboratory, and imaging findings. For 22 patients the diagnosis was considered preEUS as part of a broader differential, and in 12 patients the EUS appearance alone led to the initial suspicion of AIP. Serum IgG4 was ≥1x ULN in 42%, and ≥2xULN in only 23% of patients. None of the patients with EUS TCB diagnosis of AIP underwent surgery. In the patients with false negative EUS TCB, diagnosis was made by HISORt criteria. Over a mean follow-up of 2.6 years no false negative diagnoses of pancreatic cancer were identified. Conclusions: In a large cohort with AIP undergoing EUS TCB we show that pancreatic biopsy is safe and provides sufficient material to definitively diagnose AIP with high sensitivity. EUS TCB obviates the need for surgical intervention in this medically treatable disease.
M1396 Autoimmune Chronic Pancreatitis in Children Grzegorz Oracz, Bozena Cukrowska, Jaroslaw Kierkus, Maciej Dadalski, Jozef Ryzko, Jerzy Socha Background: In the last decade we can observe gradual increase of autoimmune diseases. The reported paediatric experience with chronic pancreatitis (CP) is small and little is known about the role of autoimmune chronic pancreatitis (AICP). Aim: The aim of the study was to assess the frequency of autoimmune markers in children with CP. Patients and Methods: During 2000 to 2009, we hospitalized 62 children with CP (33 boys and 29 girls; age 2.818 years, mean age: 11.9 years). Clinical data were recorded and analyzed. Gammaglobulins, IgG4, autoantibodies (ANA, ASMA, AMA, APCA, LKM and AHA) were measured in all children. Results: Autoimmune disease was present in 5 patients (8%): ulcerative colitis in 2 patients, PSC, dermatomiositis and panniculitis in 1 patient each. Hypergammaglobulinemia (>16g/l) was present in 10 cases. An increase of IgG4 level was present in 4 children. Autoantibodies were present in 34 children (54.8%). ANAs (>1/80e) were present in 16 patients with CP (in 6 pts >1/640e). ASMAs (>1/80e) were present in 16 children. APCAs, AMAs, AHAs and LKM were absent in all patients. Combining clinical and biochemical autoimmune parameters, 37 patients (59.7%) had at least 1 autoimmune marker of the disease. In 17 patients (27.4%) with CP and autoimmune stigmata other known causative factors of CP were present. In 14 patients we found gene mutations predisposing to CP. There was no difference in the severity of the disease and clinical course between children with autoimmune stigmata and patients without autoimmune markers. Conclusions: In children with CP, similarly to adults, there is a high frequency of clinical and biochemical markers of autoimmunity. Number of CP with autoimmune origin in children is greatly underreported.
M1394 How Common is Crohn's Pancreatitis? A 14 Year Autopsy Review Rukshana Cader, Anthony N. Kalloo, Theodore M. Bayless, Samuel A. Giday Background: In adults with Crohn's disease (CD) acute pancreatitis has been observed usually as a consequence of medications, gallstones and alcohol. A significant percentage of patients though have no known cause and the frequency of Crohn's pancreatitis is not clearly known. Aim: To estimate the frequency of Crohn's induced pancreatitis in patients with CD who had autopsies over a period of 14 years. Methods: Our prospective pathology autopsy database was queried for Crohn's disease patients that were evaluated and/or treated at Johns Hopkins Hospital from 1995 -2009. Relevant demographic, clinical, surgical, and radiographic data were recorded in those patients with evidence of pancreatitis. Results: 37 patients with CD had autopsies performed during the study period. Of these seven patients (19%) were found to have pancreatitis on histopathologic evaluation. Acute pancreatitis, manifested as neutrophilic inflammatory infiltrates and interstitial edema were seen in two patients. Mixed acute and chronic inflammation was seen in 2 more patients while the remaining three had findings consistent with chronic pancreatitis. Majority of the patients (86%) were on 5ASA drug and 6MP. The one patient who was not on any medication had evidence of gallstones. All patients with evidence of acute inflammation in the pancreas presented clinically with acute pancreatitis. The remaining 5 (71%) had no clinical history of pancreatitis but had evidence of chronic pancreatitis on histological evaluation. None of these patients had pancreatic granulomatous inflammation on histopathologic evaluation despite being present elsewhere in the GI tract. Conclusion: In this 14 year autopsy series, 19% of patients with Crohn's disease had evidence of pancreatitis. All the patients with evidence of chronic pancreatitis on histology had no clinical history of chronic or acute pancreatitis. The classic granulomatous inflammation of CDs was not present in any of our patients.
M1397 Epidemiological Study of Pancreatic Diabetes in Japan: A Nationwide Study Tetsuhide Ito, Makoto Otsuki, Hisato Igarashi, Taichi Nakamura, Nao Fujimori, Takamasa Oono, Ryoichi Takayanagi, Tooru Shimosegawa Objectives: There have been few epidemiological studies on pancreatic diabetes. In this study we determined the incidence and pathology of pancreatic diabetes in Japan. Methods: We examined the epidemiology of pancreatic diabetes in Japan in 2005 by using a nationwide stratified random sampling method. Especially, we focused on newly developed diabetes in association with the occurrence of pancreatic disease (true pancreatic diabetes). Results: A total of 19,500 individuals received treatment for true pancreatic diabetes, accounting for 0.8% of patients with diabetes. Prevalence was estimated to be 15.2/100,000 with an annual onset incidence of 1.1/100,000. With regard to the complications in true pancreatic diabetes, the incidence of retinopathy was lower than that in type 1 and 2 diabetes. Among true pancreatic diabetes with chronic pancreatitis, alcoholic pancreatitis was found in the largest sector. Furthermore as many as 53.7% were continuous drinkers, and 66.7% received insulin therapy. The frequency of hypoglycemia was high in regular drinkers treated with insulin. Hypoglycemia was a major cause of death in patients who were on insulin and continuous drinkers. Conclusion: We clarified the epidemiology of pancreatic diabetes in Japan. Patients with chronic pancreatitis-associated pancreatic diabetes should receive lifestyle guidance focused on drinking cessation. Epidemiology of pancreatic diabetes in Japan (2005)
M1395 Treatment With Liprotamase Maintains Nutritional Parameters in Subjects With Chronic Pancreatitis or Total Pancreatectomy and Exocrine Pancreatic Insufficiency Alphonso Brown, Chris Stevens, Donna S. Cohen, Marilyn Campion, Steven D. Freedman Background and Aims: Liprotamase is a novel non-porcine pancreatic enzyme replacement therapy (PERT) containing 3 highly purified microbial-derived enzymes: crystalline protease, amylase, and crystalline, cross-linked, recombinant lipase. The efficacy and safety of this PERT has been demonstrated in two well-controlled short-term studies. A one year openlabel trial was performed to study the long-term safety and tolerability of liprotamase in subjects with chronic pancreatitis (CP) or total pancreatectomy (TP) with exocrine pancreatic insufficiency (EPI). This trial also measured long-term outcomes (nutritional parameters) such as weight, and BMI. The study was terminated by the Sponsor for corporate reasons with 26 subjects completing 4 months of treatment, 14 completing at least six months and 4 completing the full 12 months of therapy. Methods: This was a 12 month open-label study in subjects with CP/TP and EPI. Subjects were ≥ 18 years of age, met criteria for CP or had undergone TP, were clinically stable, and had either clinical features of EPI or a fecal elastase < 100 μg/g. Subjects took one capsule of liprotamase (containing 32,500 units lipase activity, 25,000 units protease activity and 3,750 units amylase activity) in the middle of 3 meals and 2 snacks each day. Subjects were allowed to increase to 2 capsules per meal. Safety measures included incidence and severity of adverse events and laboratory parameters. Results: After obtaining informed consent, 39 subjects were enrolled and treated. The average number of capsules per day was 4.1 for all subjects. Liprotamase was well tolerated and there were no obvious safety signals. Nutrition was assessed by repeated measures of weight and BMI. Median weight at Baseline was 63.5 kg (n=39), 64.1 kg at month 4 (n=26), and 64.6 kg at month 6 (n=14). Median BMI was 22.2 kg/m2 at Baseline (n=39), 21.9 kg/m2 at month 4 (n=26) and 21.8 kg/m2 at month 6 (n=14). No meaningful differences in weight or BMI were observed when investigating the subgroups of drug exposure or use of acid suppression. Conclusions: The results of this study indicate that daily treatment with liprotamase resulted in the long term maintenance of nutrition as measured by weight and BMI in subjects with CP and TP. This study was supported by Alnara Pharmaceuticals Inc.
AGA Abstracts
Prevalence of diabetic complications in true pancreatic diabetes.
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