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Mo1413 Post-Endoscopic Retrograde Cholangiopancreatography 2-Hour Amylase Level Is a Useful Predictor of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis
Abstracts Frequency of post ERCP pancreatitis in both groups
valuable predictive marker for PEP. This marker could help to prevent the development of PEP early after ERCP.
Number of patient (%) Normal hydration No PEP* Mild PEP* Moderate PEP* Severe PEP* All case PEP*
28 (93.3%) 2 (6.7%) 0 (0%) 0 (0%) 2 (6.7%)
Aggressive hydration 27 (90%) 0 (0%) 3 (10%) 0 (0%) 3 (10%)
P-value 0.081
1.000
*PEP Post ERCP Pancreatitis
Mo1412 Comparison Between Ulinastatin and Nafamostat Mesylate for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Yoshiaki Kawaguchi*, Tetsuya Mine Tokai University School of Medicine, Isehara, Japan Background: It has been reported that the administration of ulinastatin, gabexate mesylate, nafamostat mesylate, NSAID, or somatostatin may be effective in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, a few trials of ulinastatin and nafamostat mesylate for the prevention of post-ERCP pancreatitis have been reported. The aim of this study was to compare the efficacy of ulinastatin and nafamostat mesylate for the prevention of post-ERCP pancreatitis. Methods: One thousand patients who underwent diagnostic and therapeutic ERCP at our hospital were divided into an ulinastatin group (n Z 500) and a nafamostat group (n Z 500). Each patient received a continuous intravenous infusion of ulinastatin (150,000 units) or nafamostat mesylate (20 mg), beginning about 60 min before the ERCP and continuing until 24 h after the ERCP. We compared the incidence of post-ERCP pancreatitis, hyperamylasemia, pain and side effect. Results: Both groups were comparable in baseline characteristics. The overall incidence of post-ERCP pancreatitis was 2.5% (twenty-five patients), comprising twelve patients in the ulinastatin group and thirteen patients in the nafamostat group (2.4% vs 2.6%, respectively). Neither of these patients developed severe pancreatitis. There were no significant differences in the serum levels of amylase or in the levels of pain between the two groups. None of the patients suffered any adverse effects related to ulinastatin or nafamostat mesylate administration. Conclusions: There was no clinical difference between the effect of preventive administration of ulinastatin and that of nafamostat mesylate on the incidence of post-ERCP pancreatitis. It would be desirable in the future to conduct further studies to determine the optimal dose and timing of the administration of ulinastatin and nafamostat for the prevention of post-ERCP pancreatitis.
Mo1413 Post-Endoscopic Retrograde Cholangiopancreatography 2-Hour Amylase Level Is a Useful Predictor of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Shiro Hayashi*, Tsutomu Nishida, Takahiro Amano, Aisa Sakamoto, Yuriko Otake, Wataru Takagi, Hirotsugu Saiki, Hisashi Kondo, Makiko Urabe, Kei Takahashi, Tokuhiro Matsubara, Masashi Yamamoto, Sachiko Nakajima, Koji Fukui, Masami Inada Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan Background: Acute pancreatitis is common complication after endoscopic retrograde cholangiopancreatography (ERCP) and called post-ERCP pancreatitis (PEP). It is sometimes potentially leading to procedure-related death, and however, difficult to completely prevent. Therefore, it is important to predict PEP to permit early intervention. Serum amylase level after ERCP-related procedure including 3-hour or 4-hour amylase levels is previously reported as a predictor of PEP, however, 2-hour amylase levels is still unclear. Aim: This study aimed to estimate the efficacy of postERCP 2-hour serum amylase levels for predicting post-ERCP pancreatitis (PEP). Material and Method: The study was a retrospective single center cohort study of consecutive patients that underwent ERCP from January 2010 to December 2013. Serum amylase levels (upper limit 120 IU/L) were measured 2 hours after the procedure. Receiver operating characteristic analysis was used to evaluate the ability of 2-hour amylase levels to predict PEP. The patient-related and procedure-related risk factors of PEP were analyzed using a logistic model. Result: A total of 1520 patients (average age 7212, men 60%) were enrolled. Of them, 117 cases with the following conditions were excluded: 1) gallstone pancreatitis, 2) unreachable to papilla, 3) missing data of procedure time or serum amylase levels. Finally, 1403 cases were analyzed. The 2-hour amylase cut-off value for PEP was 264 IU/L (AUC: 0.93). Patients with an amylase level greater than 264 IU/L (46/211, 21.8%) had a significantly higher rate of PEP than those with a lower amylase level (9/1192, 0.8%). Univariate analysis revealed 10 significant predictive factors for PEP: female sex, native papilla, cannulation time, total procedure time, endoscopic biliary stent, precut, endoscopic sphincterotomy, endoscopic papillary balloon dilation, pancreatic duct brush cytology, and 2-hour amylase level. Multivariate analysis of these factors revealed that cannulation time longer than 13 min [OR 2.1, 95% CI 1.0-4.4] and 2-hour amylase level [OR 24.3, 95% CI 11.9-55.0] were significant predictive factors for PEP. Conclusion: These findings indicate that post ERCP 2-hour serum amylase level is a
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Mo1414 Novel Risk Factors for Post - ERCP Bacteremia Liat Mlynarsky*1,2, Adam Phillips1,2, Alaa Melhem1,2, Erwin Santo1,2 1 Department of Gastroenterology, Tel Aviv Medical Center, Tel-Aviv, Israel; 2Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel Background & Aim: According to ASGE recommendations antibiotic prophylaxis is not recommended when an ERCP is likely to achieve complete biliary drainage. However, clinically significant post-ERCP bacteremia (PEB) occurs in up to 5% of cases and other risk factors are not fully established. The aim of this study was to evaluate possible risk factors for PEB in patients who were not administered antibiotics prior to ERCP. Methods: This is a retrospective cohort study characterizing 1,047 consecutive patients who underwent ERCP in the Tel-Aviv Medical Center between January 2012 - December 2013, assessing attributes of PEB. Exclusion: a) positive bacterial culture before ERCP, b) any antibiotic treatment prior to ERCP procedure, c) hospitalization longer than 14 days before ERCP. Risk factors for bacteremia were assessed by stepwise logistic regression. Results: A total of 486 procedures were included, 41.8% males, mean age 67.614.8 years. Post procedural bacterial blood cultures were drawn in 14.2% of ERCPs with a mean interval of 3.43.5 days (range 0-13 days, median 2 days). Positive cultures were documented in 4.9% of ERCPs. Age and ERCP duration were comparable between PEB and nonPEB groups. Patients older than 75 year had significantly higher prevalence of PEB (7.7% vs. 3.5%, PZ0.038). The indication with the highest rate of PEB was first intervention in an obstructive malignancy (9.3%), followed by choledocholithiasis (4.2%). Other indications included: elective stent replacement (3.9%) and benign bile duct stricture (3.6%). PEB was significantly more prevalent among tandem endoscopic ultrasound (EUS) and ERCP procedures compared to ERCP only (12.2% vs. 4.3%, PZ0.025, respectively). Patients with native papilla had a significantly higher prevalence of PEB in comparison with experienced patients (7.3% vs. 3.0% PZ0.028, respectively). TTS dilatation was utilized in 24/486 ERCPs, none resulted in PEB. There were no PEBs (0%) when metal stent was placed. Nevertheless, higher rates of PEB were not observed among type of stent comparison (plastic vs. metal) nor in biliary or pancreatic stent placement or presence of previous stent (PZNS). In a multivariate analysis three risk factors achieved statistical significance: tandem EUS-ERCP (OR 3.3, 95%CI: 1.12- 9.50), age O75 years (OR 2.7, 95%CI: 1.15-6.28) and first intervention in an obstructive malignancy (OR 2.5, 95%CI: 0.98-6.47). Conclusions: Tandem EUS - ERCP, age above 75 years and first intervention in an obstructive malignancy were found to be significant risk factors for PEB. These factors should be further studied as indications for prophylactic antibiotic treatment.
Mo1415 Incidence and Outcomes of Post-ERCP Pancreatitis During the Academic Year: Is July Dangerous? Allison R. Schulman*1, Marwan Abou Gergi2, Marvin Ryou1, Christopher C. Thompson1 1 Division of Gastroenterology, Brigham & Women, Boston, MA; 2Catalyst Medical Consulting, Towson, MD Introduction: The changeover of medical trainees at the beginning of the academic year has been shown in a variety of subspecialties to negatively impact the quality of patient care. At academic institutions, endoscopic retrograde cholangiopancreatography (ERCP) involves advanced endoscopy fellows. This procedure carries a risk of pancreatitis, and outcomes may vary based on the time of year it is performed. Aims: To assess incidence of post-ERCP pancreatitis in the early (July/August/September) versus the late (April/May/June) academic year. Secondary aims evaluate in-hospital mortality, length of stay (LOS), and total hospitalization charge between these time periods. Methods: This was a retrospective cohort study using the 2012 Nationwide Inpatient Sample (NIS), a nationally representative database of inpatient admissions. Patients with ICD-9 CM procedure codes for ERCP were included in the study. Patients were excluded if they had a principal diagnosis of acute pancreatitis or if the ERCP was performed before or on the day of admission. Post-ERCP pancreatitis was defined as an ICD-9 CM code for a secondary diagnosis of acute pancreatitis. ERCPs performed during the months of July, August and September were compared to those performed in April, May and June both in academic and non-academic hospitals. The primary outcome was incidence of post-ERCP pancreatitis. Secondary outcomes included in-hospital mortality, length of stay (LOS), and total hospitalization charge. Crude and adjusted odds ratios were calculated using univariable and multivariable regression analyses. Proportions were compared using fisher’s exact test and continuous variables using the student t-test. Results: A total of 11,553 cases were analyzed (5,642 in July/August/September and 5,911 in April/May/June) in the 2012 academic year. Incidence of post-ERCP pancreatitis in early versus late academic year were not statistically significant (OR 1.03, 95% CI [0.71-1.51]; pZ0.415). Similarly, the adjusted odds ratio of mortality in early compared to late academic year were not statistically significant. In patients who developed post-ERCP pancreatitis, adjusted odds ratio between early and late academic year for LOS (2.04 vs. 0.34, p!0.01) and total hospitalization charge ($20,990 vs. $4,861, p!0.01) were
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB411
valuable predictive marker for PEP. This marker could help to prevent the development of PEP early after ERCP.
Number of patient (%) Normal hydration No PEP* Mild PEP* Moderate PEP* Severe PEP* All case PEP*
28 (93.3%) 2 (6.7%) 0 (0%) 0 (0%) 2 (6.7%)
Aggressive hydration 27 (90%) 0 (0%) 3 (10%) 0 (0%) 3 (10%)
P-value 0.081
1.000
*PEP Post ERCP Pancreatitis
Mo1412 Comparison Between Ulinastatin and Nafamostat Mesylate for the Prevention of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Yoshiaki Kawaguchi*, Tetsuya Mine Tokai University School of Medicine, Isehara, Japan Background: It has been reported that the administration of ulinastatin, gabexate mesylate, nafamostat mesylate, NSAID, or somatostatin may be effective in the prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. However, a few trials of ulinastatin and nafamostat mesylate for the prevention of post-ERCP pancreatitis have been reported. The aim of this study was to compare the efficacy of ulinastatin and nafamostat mesylate for the prevention of post-ERCP pancreatitis. Methods: One thousand patients who underwent diagnostic and therapeutic ERCP at our hospital were divided into an ulinastatin group (n Z 500) and a nafamostat group (n Z 500). Each patient received a continuous intravenous infusion of ulinastatin (150,000 units) or nafamostat mesylate (20 mg), beginning about 60 min before the ERCP and continuing until 24 h after the ERCP. We compared the incidence of post-ERCP pancreatitis, hyperamylasemia, pain and side effect. Results: Both groups were comparable in baseline characteristics. The overall incidence of post-ERCP pancreatitis was 2.5% (twenty-five patients), comprising twelve patients in the ulinastatin group and thirteen patients in the nafamostat group (2.4% vs 2.6%, respectively). Neither of these patients developed severe pancreatitis. There were no significant differences in the serum levels of amylase or in the levels of pain between the two groups. None of the patients suffered any adverse effects related to ulinastatin or nafamostat mesylate administration. Conclusions: There was no clinical difference between the effect of preventive administration of ulinastatin and that of nafamostat mesylate on the incidence of post-ERCP pancreatitis. It would be desirable in the future to conduct further studies to determine the optimal dose and timing of the administration of ulinastatin and nafamostat for the prevention of post-ERCP pancreatitis.
Mo1413 Post-Endoscopic Retrograde Cholangiopancreatography 2-Hour Amylase Level Is a Useful Predictor of Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis Shiro Hayashi*, Tsutomu Nishida, Takahiro Amano, Aisa Sakamoto, Yuriko Otake, Wataru Takagi, Hirotsugu Saiki, Hisashi Kondo, Makiko Urabe, Kei Takahashi, Tokuhiro Matsubara, Masashi Yamamoto, Sachiko Nakajima, Koji Fukui, Masami Inada Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan Background: Acute pancreatitis is common complication after endoscopic retrograde cholangiopancreatography (ERCP) and called post-ERCP pancreatitis (PEP). It is sometimes potentially leading to procedure-related death, and however, difficult to completely prevent. Therefore, it is important to predict PEP to permit early intervention. Serum amylase level after ERCP-related procedure including 3-hour or 4-hour amylase levels is previously reported as a predictor of PEP, however, 2-hour amylase levels is still unclear. Aim: This study aimed to estimate the efficacy of postERCP 2-hour serum amylase levels for predicting post-ERCP pancreatitis (PEP). Material and Method: The study was a retrospective single center cohort study of consecutive patients that underwent ERCP from January 2010 to December 2013. Serum amylase levels (upper limit 120 IU/L) were measured 2 hours after the procedure. Receiver operating characteristic analysis was used to evaluate the ability of 2-hour amylase levels to predict PEP. The patient-related and procedure-related risk factors of PEP were analyzed using a logistic model. Result: A total of 1520 patients (average age 7212, men 60%) were enrolled. Of them, 117 cases with the following conditions were excluded: 1) gallstone pancreatitis, 2) unreachable to papilla, 3) missing data of procedure time or serum amylase levels. Finally, 1403 cases were analyzed. The 2-hour amylase cut-off value for PEP was 264 IU/L (AUC: 0.93). Patients with an amylase level greater than 264 IU/L (46/211, 21.8%) had a significantly higher rate of PEP than those with a lower amylase level (9/1192, 0.8%). Univariate analysis revealed 10 significant predictive factors for PEP: female sex, native papilla, cannulation time, total procedure time, endoscopic biliary stent, precut, endoscopic sphincterotomy, endoscopic papillary balloon dilation, pancreatic duct brush cytology, and 2-hour amylase level. Multivariate analysis of these factors revealed that cannulation time longer than 13 min [OR 2.1, 95% CI 1.0-4.4] and 2-hour amylase level [OR 24.3, 95% CI 11.9-55.0] were significant predictive factors for PEP. Conclusion: These findings indicate that post ERCP 2-hour serum amylase level is a
www.giejournal.org
Mo1414 Novel Risk Factors for Post - ERCP Bacteremia Liat Mlynarsky*1,2, Adam Phillips1,2, Alaa Melhem1,2, Erwin Santo1,2 1 Department of Gastroenterology, Tel Aviv Medical Center, Tel-Aviv, Israel; 2Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel Background & Aim: According to ASGE recommendations antibiotic prophylaxis is not recommended when an ERCP is likely to achieve complete biliary drainage. However, clinically significant post-ERCP bacteremia (PEB) occurs in up to 5% of cases and other risk factors are not fully established. The aim of this study was to evaluate possible risk factors for PEB in patients who were not administered antibiotics prior to ERCP. Methods: This is a retrospective cohort study characterizing 1,047 consecutive patients who underwent ERCP in the Tel-Aviv Medical Center between January 2012 - December 2013, assessing attributes of PEB. Exclusion: a) positive bacterial culture before ERCP, b) any antibiotic treatment prior to ERCP procedure, c) hospitalization longer than 14 days before ERCP. Risk factors for bacteremia were assessed by stepwise logistic regression. Results: A total of 486 procedures were included, 41.8% males, mean age 67.614.8 years. Post procedural bacterial blood cultures were drawn in 14.2% of ERCPs with a mean interval of 3.43.5 days (range 0-13 days, median 2 days). Positive cultures were documented in 4.9% of ERCPs. Age and ERCP duration were comparable between PEB and nonPEB groups. Patients older than 75 year had significantly higher prevalence of PEB (7.7% vs. 3.5%, PZ0.038). The indication with the highest rate of PEB was first intervention in an obstructive malignancy (9.3%), followed by choledocholithiasis (4.2%). Other indications included: elective stent replacement (3.9%) and benign bile duct stricture (3.6%). PEB was significantly more prevalent among tandem endoscopic ultrasound (EUS) and ERCP procedures compared to ERCP only (12.2% vs. 4.3%, PZ0.025, respectively). Patients with native papilla had a significantly higher prevalence of PEB in comparison with experienced patients (7.3% vs. 3.0% PZ0.028, respectively). TTS dilatation was utilized in 24/486 ERCPs, none resulted in PEB. There were no PEBs (0%) when metal stent was placed. Nevertheless, higher rates of PEB were not observed among type of stent comparison (plastic vs. metal) nor in biliary or pancreatic stent placement or presence of previous stent (PZNS). In a multivariate analysis three risk factors achieved statistical significance: tandem EUS-ERCP (OR 3.3, 95%CI: 1.12- 9.50), age O75 years (OR 2.7, 95%CI: 1.15-6.28) and first intervention in an obstructive malignancy (OR 2.5, 95%CI: 0.98-6.47). Conclusions: Tandem EUS - ERCP, age above 75 years and first intervention in an obstructive malignancy were found to be significant risk factors for PEB. These factors should be further studied as indications for prophylactic antibiotic treatment.
Mo1415 Incidence and Outcomes of Post-ERCP Pancreatitis During the Academic Year: Is July Dangerous? Allison R. Schulman*1, Marwan Abou Gergi2, Marvin Ryou1, Christopher C. Thompson1 1 Division of Gastroenterology, Brigham & Women, Boston, MA; 2Catalyst Medical Consulting, Towson, MD Introduction: The changeover of medical trainees at the beginning of the academic year has been shown in a variety of subspecialties to negatively impact the quality of patient care. At academic institutions, endoscopic retrograde cholangiopancreatography (ERCP) involves advanced endoscopy fellows. This procedure carries a risk of pancreatitis, and outcomes may vary based on the time of year it is performed. Aims: To assess incidence of post-ERCP pancreatitis in the early (July/August/September) versus the late (April/May/June) academic year. Secondary aims evaluate in-hospital mortality, length of stay (LOS), and total hospitalization charge between these time periods. Methods: This was a retrospective cohort study using the 2012 Nationwide Inpatient Sample (NIS), a nationally representative database of inpatient admissions. Patients with ICD-9 CM procedure codes for ERCP were included in the study. Patients were excluded if they had a principal diagnosis of acute pancreatitis or if the ERCP was performed before or on the day of admission. Post-ERCP pancreatitis was defined as an ICD-9 CM code for a secondary diagnosis of acute pancreatitis. ERCPs performed during the months of July, August and September were compared to those performed in April, May and June both in academic and non-academic hospitals. The primary outcome was incidence of post-ERCP pancreatitis. Secondary outcomes included in-hospital mortality, length of stay (LOS), and total hospitalization charge. Crude and adjusted odds ratios were calculated using univariable and multivariable regression analyses. Proportions were compared using fisher’s exact test and continuous variables using the student t-test. Results: A total of 11,553 cases were analyzed (5,642 in July/August/September and 5,911 in April/May/June) in the 2012 academic year. Incidence of post-ERCP pancreatitis in early versus late academic year were not statistically significant (OR 1.03, 95% CI [0.71-1.51]; pZ0.415). Similarly, the adjusted odds ratio of mortality in early compared to late academic year were not statistically significant. In patients who developed post-ERCP pancreatitis, adjusted odds ratio between early and late academic year for LOS (2.04 vs. 0.34, p!0.01) and total hospitalization charge ($20,990 vs. $4,861, p!0.01) were
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB411