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Mo1334 Validation and Comparison of the New Severity Classification Systems With Old Atlanta Classification for Severity of Acute Pancreatitis
Mo1336 Early Predictors and Outcomes of Increased Fluid Sequestration in Acute Pancreatitis Mahya Faghih, Elham Afghani, Amitasha Sinha, Joanna K. Law, Mouen Khashab, Anne Marie Lennon, Enrique de-Madaria, Vikesh K. Singh Background: Clinical guidelines recommend early and aggressive fluid therapy in patients with acute pancreatitis (AP). However prospective studies in humans have suggested that this may be detrimental due to fluid sequestration (FS). Identifying early predictors of increased FS might allow for the individualization of fluid therapy. Aims: To evaluate admission predictors associated with increased FS in the first 48 hours in patients with AP. Methods: Demographic, clinical, and laboratory data of all consecutive adults (age≥18 years) admitted with a diagnosis of AP from Jan 2010 to Jan 2013 was collected. AP was defined as 2 of the 3 criteria: characteristic abdominal pain, amylase/lipase levels >3X the upper limit of normal; and/or CT imaging consistent with AP. FS was calculated by subtracting the total amount of fluid output from input in the first 48 hours of presentation (FS 48h). Fluid output also included insensible losses (10mL/g of body weight) and temperature >37.8 C (500 mL extra fluid output/ day). Patients on hemodialysis, >2 previous episodes of AP, transfers from outside hospitals, incomplete data, underlying chronic pancreatitis (CP) as defined by the presence of calcification and/or dilated main pancreatic duct (≥ 5 mm) on past or current imaging were excluded. Comorbidity was quantified using the age-adjusted Charlson index (ACCI). BISAP was defined by BUN>25, impaired mental status, systemic inflammatory response syndrome (SIRS), age>60, and pleural effusions. Outcomes assessed included length of hospital stay, acute fluid collection(s) (AFC), pancreatic necrosis (PN), persistent organ failure (POF), and mortality. AFC, PN, and POF were defined in accordance with the revised Atlanta classification Results: There were 354 patients with AP, of whom 214 (60.5%) met the inclusion criteria (53.3% male, mean age of 47.8 ± 15.0 yrs, median ACCI of 2 [0,2], median BISAP of 1 [0,1], alcohol etiology 53.3%, median FS 48h 4.3 L [2.5, 6.1]). 3.2% of patients in the cohort developed pancreatic necrosis. Both simple and multiple linear regression analysis showed that age<40 (p<0.005), alcohol etiology (p<0.001), and SIRS (p<0.001) on admission were significantly associated with increased FS 48h. Admission hematocrit, glucose, creatinine, and BUN were not associated with increased FS 48h (p>0.05). Increased FS was significantly associated with persistent SIRS (p<0.001), POF (p<0.001), and ICU stay (p=0.008). Conclusion: Young age, alcohol etiology, and SIRS are early and independent predictors of increased FS 48h in patients with AP. Hemoconcentration was not significantly associated with increased FS in this cohort due to the small number of patients with PN. Increased FS 48 h is associated with poor outcomes.
Mo1334 Validation and Comparison of the New Severity Classification Systems With Old Atlanta Classification for Severity of Acute Pancreatitis Ragesh B. Thandassery, Manish Manrai, Pradeep K. Siddappa, Jahangeer B. Medarapalem, Sreekanth Appasani, Saroj K. Sinha, Manik Sharma, Thakur D. Yadav, Rakesh Kochhar Background Two new classification systems for the severity of acute pancreatitis (AP) have been proposed recently, the determinant based classification (DBC) and revised Atlanta classification (RAC). We aimed to validate and compare these classification systems with original Atlanta classification (OAC). Aims To validate and compare the DBC and RAC with original Atlanta classification (OAC) Methods 469 adult patients with AP admitted to a tertiary care center from January 2009-June 2013 were included in the study. The new classification systems were validated and compared in terms of outcomes (need for interventions, total hospital and intensive care unit (ICU) stay and mortality). Results The mean age of patients was 39.9±13.4 years (331 males) with the commonest etiology being alcohol (161, 34.3%) followed by gall stones (125, 26.6%). There were 119 (25.4%) patients with mild and 250 (74.6%) patients with severe AP as per OAC. Pancreatic necrosis was present in 66.1% and infected pancreatic necrosis in 23.1% patients. 126 (26.9%) patients underwent interventions (endoscopic n= 49, 10.4%, radiological n=95, 20.2% and surgical n=47, 10%). 93 (19.8%) patients died. As per DBC, 97(20.7%), 172 (36.7%), 152 (32.4%), and 48(10.2%) patients were determined to have mild, moderate, severe, and critical AP, respectively. As per RAC, 119 (25.4%), 160 (34.1%), and 190 patients (40.3%) were determined to have mild, moderately severe, and severe AP, respectively. Higher grades of severity were associated with worse outcomes in DBC, RAC and OAC. Predictive accuracies were evaluated using area under the receiver operator characteristics curve (AUROC) and Somer's D co-efficient. The DBC, RAC and OAC were comparable in predicting the need for interventions (AUROC 0.53, 0.55, 0.54, p=0.36) and length of hospital stay (Somer's D, 0.27, 0.26, 0.23, p=0.41). However, both DBC and RAC had comparable but better accuracy than OAC in predicting need for ICU admission (AUROC 0.73 for both vs. 0.62 for OAC, P<0.001), length of ICU stay (Somer's D, 0.35 for both vs. 0.24 for OAC, p<0.001) and mortality (AUROC 0.78 for both vs. 0.61 for OAC, p<0.001). Conclusion Determinant based classification and revised Atlanta classification categorize patients into subgroups that reflect clinical outcomes. Both have comparable and higher predictive accuracy than old Atlanta classification for need for ICU admission, length of ICU stay and mortality.
Mo1337 Risk Factors for the Development of Intra-Abdominal Fungal Infections in Acute Pancreatitis Timothy B. Gardner, Stuart R. Gordon Background & Aims: Intra-abdominal pancreatic fungal infections (PFI) complicating acute pancreatitis arise proportionally to the extent of pancreatic necrosis, although risk factors for the development of PFI are not well characterized. We aimed to determine risk factors which contributed to PFI in patients with acute pancreatitis. Methods: Records were reviewed from a large single center database of 479 non-transferred patients with acute pancreatitis admitted to our medical center from 1985-2009. Demographic, procedural, and outcomes data were abstracted with the primary outcome being the presence of a culture-confirmed pancreatic fungal infection. Results: Out of 479 patients admitted to our medical center for acute pancreatitis, 17 were subsequently found to have an intra-abdominal fungal infection and 3 of these patients died. The median length of stay for patients with PFI was 24 days and 77% were admitted to the intensive care unit. C. albicans was the most frequently encountered organism, followed by C. tropicalis and C. krusei. Patients with intra-abdominal fungal infections were more likely to have received prophylactic admission antibiotics (OR 1.7, 95% C.I. 1.2-2.3), TPN within 7 days of admission (OR 1.4, 95% C.I. 1.1-1.7), and to have necrosis on CT scan within 7 days of admission (OR 1.4, 95% C.I. 1.1-1.7). The degree of necrosis (<50% vs. >50% glandular necrosis) was not more predictive of risk. Aggressive fluid resuscitation (greater than 1/3 of 72 hour IV fluids given within the first 24 hours - OR 0.9, 95% C.I. 0.7-1.3), age >60 years, gender were not protective against the development of PFI. Multivariable regression identified admission antibiotic use (OR 1.6, 95% C.I. 1.4-1.8) as the strongest predictor for PFI. Conclusion: Although rare, pancreatic fungal infections are a source of considerable morbidity and mortality. Because the prophylactic use of admission antibiotics is the best predictor for the development of PFI, they should be avoided in patients with acute pancreatitis.
Mo1335 Systemic Inflammatory Response Syndrome (SIRS) in Acute Pancreatitis (AP): Outcome of Early Fluid Therapy Mahya Faghih, Elham Afghani, Amitasha Sinha, Mouen Khashab, Joanna K. Law, Anne Marie Lennon, Enrique de-Madaria, Vikesh K. Singh Background: SIRS is common among AP patients presenting to ED. Fluid therapy has been associated with a reduction in SIRS. Aims: To evaluate the effect of fluid therapy among AP patients with SIRS in ED & SIRS within 24 hrs on medical ward (MW). Methods: Demographic, clinical, & laboratory data was collected on all adult AP patients admitted to medical ward (MW) from ED between 1/10-1/13 in the first 7 days of admission. Exclusion criteria included: no SIRS in ED, outside hospital transfers, prolonged ED course (>24 hrs), current hemodialysis, >2 previous episodes of AP, incomplete data, & underlying chronic pancreatitis (presence of calcification and/or main pancreatic duct ≥ 5 mm). Comorbidity was assessed using Charlson comorbidity index (CCI). The fluid administered in ED was compared in patients with & without SIRS on admission to MW. We also evaluated fluid administered within initial 24 hrs of presentation to MW & outcomes in patients who developed persistent SIRS (>48 hrs) in MW. Persistent organ failure (POF), acute fluid collections (AFC) & pancreatic necrosis were defined using the revised Atlanta classification. We also evaluated length of stay (LOS), need for nutritional support, need for invasive treatments, ICU stay, & mortality. Results: A total of 199 AP patients presented to ED, of whom 76 (38.2%) met inclusion criteria, (60.5% males, mean age of 47 ± 13.9 years, median CCI of 1 [0,2], & alcoholic etiology in 63.2%). Mean time spent in ED was 10.9 ± 4.8 hrs & mean duration of symptoms prior to presentation was 3.8 ± 4.9 days. Of these, 44 (57.9%) continued to have SIRS within 24 hrs of admission to MW while 32(42.1%) had resolution of SIRS. There were no significant differences between the two groups in terms of etiology, CCI, time spent in ED, duration of symptoms prior to presentation, BUN, hematocrit (HCT), & creatinine (Cr). There was no significant difference between total fluids administered in ED between those who continued to have SIRS as compared to those who had resolution of SIRS in MW (2.8 ± 1.6 L vs. 2.4 ± 1.3 L, p= 0.08). Of the 44, 20(45.4%) developed persistent SIRS. There were no significant differences between those with persistent SIRS & those who did not develop persistent SIRS (n=24) with regards to BUN, Cr, HCT, total fluids received in 24 hours on MW (p>0.05). The 20 patients who developed persistent SIRS had significantly more need for nutritional support (20% vs. 0%, p= 0.02), AFC (50% vs. 12.5%, p=0.007),
Mo1338 Comparative Evaluation of Abdominal Ultrasound, Endoscopic Ultrasound and Magnetic Resonance Imaging in Detecting Solid Necrotic Debris in Walled off Pancreatic Necrosis Vinita Chaudhary, Ravi Sharma, Surinder S. Rana, Vishal Sharma, Puneet Chhabra, Deepak K. Bhasin Introduction: Walled off pancreatic necrosis (WON) is an important complication of acute necrotising pancreatitis which is usually diagnosed using investigations like endoscopic ultrasound (EUS)/ magnetic resonance imaging (MRI) that can visualize the necrotic debris better. However, these investigations are expensive and not widely available. The role of abdominal ultrasound, an inexpensive and widely available investigation, in WOPN is not
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POF (20% vs. 0%, p=0.02), and longer LOS (20.5 ± 35.7 vs. 3.9 ± 2.36, p=0.03) when compared to the 24 patients who did not have persistent SIRS. Conclusion: SIRS that does not resolve by the time of hospital admission in AP is associated with a nearly 50% risk of developing persistent SIRS & these patients are at risk for poor outcomes. Early fluid administration did not attenuate SIRS in this cohort.
Mo1334 Validation and Comparison of the New Severity Classification Systems With Old Atlanta Classification for Severity of Acute Pancreatitis Ragesh B. Thandassery, Manish Manrai, Pradeep K. Siddappa, Jahangeer B. Medarapalem, Sreekanth Appasani, Saroj K. Sinha, Manik Sharma, Thakur D. Yadav, Rakesh Kochhar Background Two new classification systems for the severity of acute pancreatitis (AP) have been proposed recently, the determinant based classification (DBC) and revised Atlanta classification (RAC). We aimed to validate and compare these classification systems with original Atlanta classification (OAC). Aims To validate and compare the DBC and RAC with original Atlanta classification (OAC) Methods 469 adult patients with AP admitted to a tertiary care center from January 2009-June 2013 were included in the study. The new classification systems were validated and compared in terms of outcomes (need for interventions, total hospital and intensive care unit (ICU) stay and mortality). Results The mean age of patients was 39.9±13.4 years (331 males) with the commonest etiology being alcohol (161, 34.3%) followed by gall stones (125, 26.6%). There were 119 (25.4%) patients with mild and 250 (74.6%) patients with severe AP as per OAC. Pancreatic necrosis was present in 66.1% and infected pancreatic necrosis in 23.1% patients. 126 (26.9%) patients underwent interventions (endoscopic n= 49, 10.4%, radiological n=95, 20.2% and surgical n=47, 10%). 93 (19.8%) patients died. As per DBC, 97(20.7%), 172 (36.7%), 152 (32.4%), and 48(10.2%) patients were determined to have mild, moderate, severe, and critical AP, respectively. As per RAC, 119 (25.4%), 160 (34.1%), and 190 patients (40.3%) were determined to have mild, moderately severe, and severe AP, respectively. Higher grades of severity were associated with worse outcomes in DBC, RAC and OAC. Predictive accuracies were evaluated using area under the receiver operator characteristics curve (AUROC) and Somer's D co-efficient. The DBC, RAC and OAC were comparable in predicting the need for interventions (AUROC 0.53, 0.55, 0.54, p=0.36) and length of hospital stay (Somer's D, 0.27, 0.26, 0.23, p=0.41). However, both DBC and RAC had comparable but better accuracy than OAC in predicting need for ICU admission (AUROC 0.73 for both vs. 0.62 for OAC, P<0.001), length of ICU stay (Somer's D, 0.35 for both vs. 0.24 for OAC, p<0.001) and mortality (AUROC 0.78 for both vs. 0.61 for OAC, p<0.001). Conclusion Determinant based classification and revised Atlanta classification categorize patients into subgroups that reflect clinical outcomes. Both have comparable and higher predictive accuracy than old Atlanta classification for need for ICU admission, length of ICU stay and mortality.
Mo1337 Risk Factors for the Development of Intra-Abdominal Fungal Infections in Acute Pancreatitis Timothy B. Gardner, Stuart R. Gordon Background & Aims: Intra-abdominal pancreatic fungal infections (PFI) complicating acute pancreatitis arise proportionally to the extent of pancreatic necrosis, although risk factors for the development of PFI are not well characterized. We aimed to determine risk factors which contributed to PFI in patients with acute pancreatitis. Methods: Records were reviewed from a large single center database of 479 non-transferred patients with acute pancreatitis admitted to our medical center from 1985-2009. Demographic, procedural, and outcomes data were abstracted with the primary outcome being the presence of a culture-confirmed pancreatic fungal infection. Results: Out of 479 patients admitted to our medical center for acute pancreatitis, 17 were subsequently found to have an intra-abdominal fungal infection and 3 of these patients died. The median length of stay for patients with PFI was 24 days and 77% were admitted to the intensive care unit. C. albicans was the most frequently encountered organism, followed by C. tropicalis and C. krusei. Patients with intra-abdominal fungal infections were more likely to have received prophylactic admission antibiotics (OR 1.7, 95% C.I. 1.2-2.3), TPN within 7 days of admission (OR 1.4, 95% C.I. 1.1-1.7), and to have necrosis on CT scan within 7 days of admission (OR 1.4, 95% C.I. 1.1-1.7). The degree of necrosis (<50% vs. >50% glandular necrosis) was not more predictive of risk. Aggressive fluid resuscitation (greater than 1/3 of 72 hour IV fluids given within the first 24 hours - OR 0.9, 95% C.I. 0.7-1.3), age >60 years, gender were not protective against the development of PFI. Multivariable regression identified admission antibiotic use (OR 1.6, 95% C.I. 1.4-1.8) as the strongest predictor for PFI. Conclusion: Although rare, pancreatic fungal infections are a source of considerable morbidity and mortality. Because the prophylactic use of admission antibiotics is the best predictor for the development of PFI, they should be avoided in patients with acute pancreatitis.
Mo1335 Systemic Inflammatory Response Syndrome (SIRS) in Acute Pancreatitis (AP): Outcome of Early Fluid Therapy Mahya Faghih, Elham Afghani, Amitasha Sinha, Mouen Khashab, Joanna K. Law, Anne Marie Lennon, Enrique de-Madaria, Vikesh K. Singh Background: SIRS is common among AP patients presenting to ED. Fluid therapy has been associated with a reduction in SIRS. Aims: To evaluate the effect of fluid therapy among AP patients with SIRS in ED & SIRS within 24 hrs on medical ward (MW). Methods: Demographic, clinical, & laboratory data was collected on all adult AP patients admitted to medical ward (MW) from ED between 1/10-1/13 in the first 7 days of admission. Exclusion criteria included: no SIRS in ED, outside hospital transfers, prolonged ED course (>24 hrs), current hemodialysis, >2 previous episodes of AP, incomplete data, & underlying chronic pancreatitis (presence of calcification and/or main pancreatic duct ≥ 5 mm). Comorbidity was assessed using Charlson comorbidity index (CCI). The fluid administered in ED was compared in patients with & without SIRS on admission to MW. We also evaluated fluid administered within initial 24 hrs of presentation to MW & outcomes in patients who developed persistent SIRS (>48 hrs) in MW. Persistent organ failure (POF), acute fluid collections (AFC) & pancreatic necrosis were defined using the revised Atlanta classification. We also evaluated length of stay (LOS), need for nutritional support, need for invasive treatments, ICU stay, & mortality. Results: A total of 199 AP patients presented to ED, of whom 76 (38.2%) met inclusion criteria, (60.5% males, mean age of 47 ± 13.9 years, median CCI of 1 [0,2], & alcoholic etiology in 63.2%). Mean time spent in ED was 10.9 ± 4.8 hrs & mean duration of symptoms prior to presentation was 3.8 ± 4.9 days. Of these, 44 (57.9%) continued to have SIRS within 24 hrs of admission to MW while 32(42.1%) had resolution of SIRS. There were no significant differences between the two groups in terms of etiology, CCI, time spent in ED, duration of symptoms prior to presentation, BUN, hematocrit (HCT), & creatinine (Cr). There was no significant difference between total fluids administered in ED between those who continued to have SIRS as compared to those who had resolution of SIRS in MW (2.8 ± 1.6 L vs. 2.4 ± 1.3 L, p= 0.08). Of the 44, 20(45.4%) developed persistent SIRS. There were no significant differences between those with persistent SIRS & those who did not develop persistent SIRS (n=24) with regards to BUN, Cr, HCT, total fluids received in 24 hours on MW (p>0.05). The 20 patients who developed persistent SIRS had significantly more need for nutritional support (20% vs. 0%, p= 0.02), AFC (50% vs. 12.5%, p=0.007),
Mo1338 Comparative Evaluation of Abdominal Ultrasound, Endoscopic Ultrasound and Magnetic Resonance Imaging in Detecting Solid Necrotic Debris in Walled off Pancreatic Necrosis Vinita Chaudhary, Ravi Sharma, Surinder S. Rana, Vishal Sharma, Puneet Chhabra, Deepak K. Bhasin Introduction: Walled off pancreatic necrosis (WON) is an important complication of acute necrotising pancreatitis which is usually diagnosed using investigations like endoscopic ultrasound (EUS)/ magnetic resonance imaging (MRI) that can visualize the necrotic debris better. However, these investigations are expensive and not widely available. The role of abdominal ultrasound, an inexpensive and widely available investigation, in WOPN is not
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POF (20% vs. 0%, p=0.02), and longer LOS (20.5 ± 35.7 vs. 3.9 ± 2.36, p=0.03) when compared to the 24 patients who did not have persistent SIRS. Conclusion: SIRS that does not resolve by the time of hospital admission in AP is associated with a nearly 50% risk of developing persistent SIRS & these patients are at risk for poor outcomes. Early fluid administration did not attenuate SIRS in this cohort.