Metastatic Signet-Ring Cell Carcinoma Presenting as Acute Pancreatitis

AGA Abstracts Figure 1: Forest plot showing adjusted hazard ratios for the association between statin use and overall survival in PanC patients

Sa1328 ENDOSCOPIC ULTRASONOGRAPHY (EUS) FOR THE DIAGNOSIS AND TREATMENT OF PANCREATIC CYSTIC LESIONS: A SINGLE-CENTER EXPERIENCE OF 136 PATIENTS Enqiang Linghu This is an invitation for me to give an presentation on May 9,2017 during ASGE/Chinese Society of Gastroenterology (CSGE) International Symposium.

Background EUS-guided ablation of pancreatic cystic lesions(PCNs) has been reported using ethanol with or without paclitaxe,yet use of lauromacrogol for ablation of PCNs has not been reported.We aimed to explore the diagnosis and treatment of pancreatic cystic lesions by EUS,emphasizing EUS-guided ablation of PCNs with lauromacrogol. Methods From April 2015 to October 2016,136 patients withPCNs were enrolled and 53 were male and 83 female with an average age of 50.1 yrs.All patients received EUS and CE-EUS.Cyst fluid was sent for cytology in 117 patients.SpyGlass was performed in 73 patients,intra-cystic biopsy in 36 patients and histology analysis in 14 patients.Pancreatic cystic ablation was performed in 30 patients.EUS-guided needle-based RFA was perfomed in 2 patients. Results Diagnostic accuracy of EUS on PCNs: 1.Accuracy of EUS to determine malignancy of PCNs is 97.0%(65/67) with sensitivity of 98.2%(56/57)and specificity of 90.0%(65/67).Accuracy of EUS to predict the pathology results is 82.1%(55/67). 2.For PCNs with multiple cysts, accuracy of EUS to determine malignancy of PCNs is 95.2%(40/42) ,and accuracy to predict the pathology results is 85.7%(36/42). 3.For PCNs with single cyst, accuracy of EUS to determine malignancy of PCNs is 100%(24/24),and accuracy to predict the pathology results is 80%(20/25). Methodology of diagnosis of PCNs 1.CE-EUS can help to determine the nature of a papilla-like structure. 2.Accuracy of cyst fluid cytology to predict the pathology results is 90.9%(40/44). 3.Accuracy of intra-cystic biopsy to predict the pathology results is 83.3%(5/6). 4.SpyGlass can help to make diagnosis of PCNs based upon smoothness of the inner cystic wall,cystic vessels,papilla-like structure,crest or crest-like structure. Pancreatic cystic ablation Pancreatic cystic ablation was performed in 30 patients.Complication rate was 7.5%(3/40):3 cases of mild pancreatitis occurred but cured within 1 week.Effectiveness:Response rate was 74.1%(20/27). Case, femal,33 yrs, SCN. Fig. 1 Imaging before and after ablation RFA(radial frequency ablation) for PCNs RFA has been performed in 2 patient,but they are still in follow up. Conclusions: EUS,CE-EUS,cyst fluid analysis,EUSbased intracystic SpyGlass and biopsy are reliable to make a definite diagnosis of PCNs.EUSguided lauromacrogol ablation for PCNs is primarily safe and effective. Fig.2 Invitation letter.

Sa1329 METASTATIC SIGNET-RING CELL CARCINOMA PRESENTING AS ACUTE PANCREATITIS Matthew J. Fasullo, Daniel Kaufman Introduction Signet-ring cell carcinoma (SRCC), an uncommon subtype of adenocarcinoma, can arise from virtually all organs. The classical appearance is related to the production of intracytoplasmic mucin to compress the nucleus against the cell wall.1 Most SRCC arise from stomach (>90%) and accounts for approximately 25% of all gastric cancer. Occurrence elsewhere within the GI tract is far less common, and accounts for less than 1% of all other GI malignancies.2 Intra-abdominal metastases tend to involve the serosal surface, retroperitoneum, and gastric mucosa.3,4 While it is usually possible to determine the primary origin, extensive examination fails to demonstrate the primary site in approximately 3-5% of oncology cases.6 Because identification of the primary site of cancer usually dictates the treatment and expected prognosis, the inability to identify a primary site poses many challenges. Clinical Presentation A 48-year old male with no significant past medical history presented to the ED with three days of abdominal pain, nausea and vomiting. Laboratory data in the ED revealed normal electrolytes and liver function tests (LFT) but revealed a lipase of 525 U/L. A CT scan demonstrated diffuse tissue stranding surrounding the pancreas with mesenteric and retroperitoneal lymphadenopathy. He was treated for pancreatitis and evaluation for potential etiologies was undertaken. He denied any recent alcohol intake and additional data, including, IgG4, triglycerides and an abdominal ultrasound were unrevealing. He responded appropriately to conservative management and was discharged. He re-presented to the ED one week later with similar symptoms. He was found to have LFTs significant for an alkaline phosphatase of 300 IU/L, T bilirubin of 11.7 mg/dL, D bilirubin of 7.5 mg/dL without transaminitis. The patient underwent ERCP and EUS, which demonstrated a round, heterogeneous mass at the pancreatic head as well as a congested and edematous major papilla that appeared fibrosed. FNA of the mass and nodes revealed pathology consistent with SRCC (Image 1) with BRAF, KRAS, and TP53 mutations. Immunophenotype staining was positive for keratin 20 and CDX2 and negative for cytokeratin 7 (Image 2), most consistent with a lower GI primary. An EGD with gastric biopsies was negative, as was a colonoscopy. Conclusion We present a rare case of SRCC presenting as acute pancreatitis. Our case had an EGD with negative biopsies along with imaging that was unremarkable for any gastric primary. While there are few case reports that have had pancreatitis associated with SRCC, nearly all reported cases have been from Ampulla of Vater metastasis which was not observed in our case. In conclusion we hope that by presenting our case of SRCC presenting as pancreatitis we can broaden our breadth of knowledge of clinical scenarios to hasten diagnosis and, subsequently, treatment.

Before ablation(Left):size of PCN was 2.8x2.4cmx2.4cm.After ablation : invisible

AGA Abstracts

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Background & Aim: Thrombosis of Splanchnic Veins (TSV) is a potentially severe complication of acute pancreatitis. It most commonly affects the splanchnic, portal or superior mesenteric veins. Acute pancreatitis (AP) is the most common gastrointestinal discharge diagnosis in the United States. The aim of this single-center, retrospective cohort study was to investigate the incidence of TSV and to determine the connected risk factors and outcomes. Methods: We performed a retrospective cohort study of consecutive patients admitted with a very first episode of acute pancreatitis at a large public hospital between 01/2013 and 12/ 2014. We identified acute pancreatitis diagnosis by ICD9 code and/or lipase ≥ 3 times the normal upper limit. Two physicians reviewed each case to include only first episodes of acute pancreatitis. We excluded patients who were transferred to our center. We reviewed the abdominal CT scans with contrast from that admission to look for New thrombosis of the Splanchnic Veins. We constructed multivariable logistic regression models using STATA software version 13. Results: We analyzed 460 patients. Mean age was 48 years (range 17 to 89 years), 54% were males. Of 460 acute pancreatitis patients, 108 had an IV contrast enhanced abdominal CT scan. The prevalence of TSV was 6% (7 cases). According to the most common affected vessel we found: Portal vein (4 cases), Splenic vein (2 cases) and SMV (1 case). Only 1 of the 7 cases was anticoagulated; this case was the only death between the 7 cases. The prevalence of pancreatic necrosis was 19%, SIRS on admission was 31%, persistent SIRS at 48h was 19% and AKI was 24%. In Univariate analysis, Alcohol intake, male gender and smoking were found to be risk factors for TSV. In Multivariate analysis the only risk factor for TSV was smoking tobacco (aOR: 1.2, p<0.001; CI 1.1-1.4). We found that AKI was less common among patients without TSV when compared to the TSV group (OR: 0.2; p<0.05; CI 0.2-0.9). After adjusting for admission SIRS, age and gender; TSV was not found to be an independent risk factor for Persistent SIRS, AKI, ARDS, pancreatic necrosis, mortality, ICU, LOS, in-hospital infections, BISAP score, nor recurrent AP. In addition, no significant difference in the recanalization rates was found in those with and without AC (p=NS). Limitations: Retrospective study. Strength: Robust patient cohort. Absence of transferred patients. Conclusion: Thrombosis of Splanchnic Veins incidence was found to be low in our cohort when compared to the reported literature. Moreover, TSV was Not found to impact the outcomes of acute pancreatitis. Smoking should call the physician's attention on the risk of abdominal vein thrombosis in acute pancreatitis. Anticoagulation of abdominal vein thrombosis is still a controversy and no benefit was found in our cohort.

H&E Staining consistent with signet-ring cell carcinoma from pancreas

Left to right : CDX positive, Cytokeratin 20 positive, Cytokeratin 7 negative. This staining pattern would be quite unusual for a pancreatic neoplasm

Sa1330 ARE INTERLEUKINS USEFUL IN PREDICTING THE SEVERITY OF ACUTE PANCREATITIS? Davorin B. C´eranic´, Pavel Skok, Milan Zorman Introduction Severe acute pancreatitis (SAP) develops in 15-25% of patients this disease. Prediction of severity is crucial in clinical practice. Aims To evaluate the role of interleukins and inflammatory markers in a prospective study. Patients and methods Included were 96 patients with AP. Laboratory parameters were analyzed on admission, after 48 hours and during hospitalisation, daily. A binomial logistic regression was performed. Results In the study were 59 (61.5%) males and 37 (38.5%) females, average age 61.5±15.9 years. The etiology was identified as gallstones in 52 %, alcohol in 33 % and other causes in 14 % . Three patients (3%) died due to multi-organ failure. Interleukin-6 (IL-6) has the greatest predictive value in prediction of SAP at admission (AUC=0.78) and after 48 hours (AUC= 0.84). IL-8 (AUC=0.70); IL-10 (AUC=0.74) were also useful markers. In comparison between the values at admission and after 48 hours, CRP has been shown to have better predictive value at follow up (AUC=0.82). At cut-off value of 152, the sensitivity was 81.3% and specificity 68.8%. Useful predictors of SAP were also LDH (p<0,001), serum glucose (p<0,006), difference in platelets between the first and the third day (p<0,001), hemoglobin (p<0,027) and erythrocytes values (p<0,029). Conclusions IL and listed markers are useful in predicting the severity of AP. According to results of our study, IL-6 and CRP after 48 hours had the best predictive value.

Sa1333 DOES CONCURRENT DIABETIC ACIDOSIS AFFECT CLINICAL COURSE IN PATIENTS WITH HYPERTRIGLYCERIDEMIA PANCREATITIS? Yuchen Wang, Bashar M. Attar, Sara Bedrose, C. Roberto Simons-Linares Backgroud: Hypertriglyceridemia induced acute pancreatitis (HP) is an uncommon condition representing 1-4 percent of overall acute pancreatitis cases. As poor glycemic control in patients with concurrent diabetes represents one of the leading cause, diabetic ketoacidosis (DKA) is frequently associated with HP. The present study aims to characterize HP patients with and without DKA, describe whether and how DKA affects the clinical course of HP. Method: We retrospectively analyzed patients with diagnosis HP (ICD9/10 code for hypertriglyceridemia and ICD 9/10 code for acute pancreatitis) at a large public hospital during 10 years (05/2006 through 05/2015). Diagnosis was confirmed with radiographicproven acute pancreatitis and concurrent serum triglyceride exceeding 1000mg/dl. We collected information regarding basic epidemiologic characters, initial laboratory results, complications from HP and hospital courses. Differences in each variable were compared between DKA group and non-DKA group; BISAP, SOFA, RANSON, APACHE II scores were calculated and compared between groups. . Results: 140 patients with complete profile were included, concurrent DKA was prevalent in 37 (26.4%) cases. Mean (SD) age was 39.6 (9.8) years; 107 (76.4%) were male; mean BMI (SD) was 30.5 (5.7) kg/m2. 65 (46.4%) patients had diabetes mellitus and 60 (42.8%) patients had known history of hyperlipidemia. While significantly more patients with DKA were male (89.2% vs 71.8%, p=0.041) and active illicit drug abuser (18.9% vs 6.8%, p=0.035), there was no statistical difference between groups in age, past medical history, tobacco or alcohol usage and BMI. DKA patient had higher serum glucose and lower serum bicarbonate as anticipated, however no significant difference exist regarding serum lipase, triglyceride, leukocyte count and lactate dehydrogenase. The mean (SD) hospitalization was 7.3 (5) days, with 3.6% (5 cases) mortality. 79 (56.4%) patients received intravenous insulin infusion with mean (SD) length of 4.1 (3.2) days. In DKA group, 62.2% patients had concurrent acute kidney injury during hospitalization, significantly more than non-DKA group (p=0.042). There were no difference in BISAP score and SOFA score between groups, however RANSON score was significantly higher in DKA group (3.97, SD=1.42)than in non-DKA group(2.88 SD=1.78) (p=0.001). Similar results exist for APACHE II score (7.70, SD=4.26 vs 5.39, SD=4.44, p=0.007). Conclusions: Concurrent DKA is prevalent is significant portion of HP cases. Male gender, active illicit drug abuser were more prevalent in DKA group. No significant difference in clinical course exist except for more acute kidney injury with DKA. RANSON score and APACHE II score were significantly higher with DKA, likely representing influences from higher serum glucose and serum bicarbonate, which are accounted in these scoring systems. Clinical course of pateints with and without DKA

Sa1331 CLINICAL IMPLICATION OF REFEEDING SYNDROME BASED ON THE ANALYSIS OF CAUSES OF EARLY MORTALITY IN ACUTE PANCREATITIS Hyun Sun Woo, Jae Hee Cho, Eui Joo Kim, YeonSuk Kim, Suji Kim Background/Aims: Italy's survey reported overall mortality rate of acute pancreatitis (AP) was approximately 5 percent. However early mortality within 3 days of AP has been unexplained. We suspected malnourished patients with AP were related with refeeding syndrome (RFS) causing cardiac failure, elevated liver-function values, etc. It was resulted from fluid and electrolyte shifts during nutritional rehabilitation. Methods: Between 2006 and 2016, 2121 patients were diagnosed with AP in two tertiary medical centers. Among them, 39 (1.8%) patients died in 3 days after admission, and clinical data were retrospectively reviewed. Results: Among 39 AP patients with early mortality, mean age was 60.1 years (range, 27 to 92 years) and there were 30 male patients. The most common cause of AP was alcohol consumption (n=28, 71.8%). Gallstones (n=7, 17.9%), malignancy (n=1, 2.6%) and hypertriglyceridemia (n=1, 2.6%) also induced AP. The causes of early mortality of AP were septic shock (n=15, 38.5%), cardiogenic shock (n=14, 36%), alcoholic ketoacidosis (n=3, 7.7%), arrhythmia (n=5, 12.8%) and respiratory failure (n=2, 5.1%). RFS was suspected in 9 (23%) patients and they were alcoholics with poor nutritional status. After sudden nutritional support, electrolyte imbalance including levels of phosphorus got progressively worse and caused death. We compared variables of 9 patients with RFS and 30 patients without RFS. Patients with RFS had significant lower levels of phosphorus. Conclusions: The 23% of early mortality of AP was related to the refeeding syndrome. Therefore, clinicians should not ignore the possibility of refeeding syndrome in malnourished AP patients with electrolyte imbalance.

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THROMBOSIS OF SPLANCHNIC VEINS DURING A FIRST EPISODE OF ACUTE PANCREATITIS: PREVALENCE AND OUTCOMES Yuchen Wang, Bashar M. Attar, Palashkumar Jaiswal, Diana Plata, Harry Fuentes, Luis Paz Rios, William Trick, C. Roberto Simons-Linares