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Nutritional status of patients with chronic pancreatitis admitted to a tertiary care center
AJG – September, 2000
Center
1
Total 380 ERCP Grade 1 87 (%) Grade 2 9 (%) Grade 3 4 (%) Level of Procedure Difficulty Grade 1 Diagnostic ERCP
Abstracts
2
3
4
5
6
7
Total
928
3878
405
778
736
751
8094
91
37
72
77
82
73
60
7
11
22
11
9
14
11
3
52
7
11
9
13
29
Success Procedure Success Procedure % (n) % (n) 94 Standard 97 Stone (2342) sphincterotomy (2154) extraction 7) 69 Stone extraction 61 (63) (1087) ([gt10mm)]
Grade 2 Minor papilla cannulation Grade 3 Diagnostic 60 (20) Manometry ERCP in Roux-en-Y/ whipple’s
Success Procedure Success % (n) % (n) 87 Biliary 97 (937) Stents (1431)
87 (1203)Intrahepatic 50 (58) Pancreatic 73 (66) stone stone extraction extraction
237 Endoscopic management of primary sclerosing cholangitis (PSC) results in slowing of disease progression Mahadevan MD Uma, Bass MD Nathan, Ostroff MD James. University of California, San Francisco. Purpose: The effect of endoscopic intervention on the progression of PSC was studied. Methods: Endoscopic Retrograde Cholangiopancreatography (ERCP) was employed for diagnosis and therapy in PSC patients with jaundice, pruritis, sepsis or liver failure as a bridge to transplantation. Endoscopic sphincterotomy and balloon dilation without stent placement was used in symptomatic patients with multifocal PSC with extrahepatic and intrahepatic strictures. Dilation was attempted to secondary branches of the right and left lobe and dominant extrahepatic strictures with 4 – 6 mm dilating balloons. From 1992–1999, PSC patients who underwent ERCP with balloon dilation were compared with PSC patients awaiting transplantation who did not undergo therapeutic intervention. The endpoints were liver transplant, death, Child-Pugh score and the modified Mayo score. Rates of change in scores were compared using the Mann-Whitney test. Results: Patient characteristics are listed in the table. 17 patients underwent 127 ERCP’s with dilation. 1 episode of pancreatitis occurred. There were no procedure-related perforations or episodes of cholangitis. There were 5 transplants in the dilated group and 1 in the nondilated group. There was 1 death in the dilated group and 3 deaths in the nondilated group. There was a trend toward slower disease progression in the dilated group. The mean change and mean rate of change per year in the Child’s score was 0.53 vs. 1.67 (p ⫽ .41) and ⫺0.79 vs. 2.30 (p ⫽ .46) for the dilated and nondilated groups respectively. The mean change and mean rate of change per year in Mayo score was .13 vs. .61 (p ⫽ .36) and ⫺1.37 vs. 0.63 (p ⫽ .48) for the dilated and nondilated groups respectively. Conclusion: ERCP with balloon dilation and without endoprosthesis usage is a safe procedure in patients with advanced PSC. Periodic dilation may slow disease progression in these patients.
Dilated Nondil.
n
Mean age
M:F
IBD (%)
Mean duration PSC
17 9
45 45
9:8 8:1
88 78
6.2 4.9
Mean bilirubin (mg/dl)
Mean follow up (mos)
Follow up range (mos)
4.8 5.6
11.8 18.2
1–36 5–40
238 Primary pancreatic lymphoma diagnosed by endoscopic ultrasound Mann MD FACG SK, Condon MD D, Mann MD FACG NS, Leung MD FACG JW. VA Medical Center, Univ of Calif, Davis Medical Center, Sacramento.
2481
Primary pancreatic lymphoma (PPL) which originates and remains localized to pancreas is very rare (Pancreas 7:1118, 1992). Without histelogic examination, it cannot be differentiated from pancreatic carcinoma; the differentiation is important as treatment and prognosis are different. US, CAT and ERCP findings are not pathognomonic. Rarer still is PPL presenting as acute pancreatitis (AP) (Gastroenteral Clin Biol 23:528, 1999). We present a case of PPL which presented as AP and was diagnosed by EUS ⫹ FNA. Case Report: 78 year old male developed abdominal pain and had the clinical and biochemical criteria of AP CAT abdomen and US abdomen were unhelpful. ERCP showed a filling defect in the main pancreatic duct without ductal dilation, and impression was pancreatic carcinoma and pancreatic stent was placed with symptomatic improvement. EUS and FNA was performed to obtain histalogic diagnosis. EUS-FNA showed large B-cell non-hodgkin lymphoma. Extensive work up and bone-marrow showed no evidence of lymphoma at any other site. Radiotherapy and chemotherapy resulted in symptomatic relief; follow up EUS showed regression of PPL but not complete resolution. Discussion: PPL especially presenting as AP is very rare. CAT and US findings are not pathognomonic and may be similar to pancreatic carcimona. Differentiation is important as the treatment and prognosis are different. Conclusion: EUS-FNA was successfully used to diagnose a case of PPL which presented as AP.
239 Nutritional status of patients with chronic pancreatitis admitted to a tertiary care center Matarese RD Laura E, Conwell MD* Darwin L, Seidner MD Douglas L, Zuccaro MD Gregory, Steiger MD Ezra. The Cleveland Clinic Foundation, Cleveland, Ohio, United States. Purpose: Patients with chronic pancreatitis (CP) are at increased risk of developing protein calorie malnutrition (PCM) due to pancreatic insufficiency and inadequate oral intake due to post prandial pain. It is important to assess the nutritional status of these patients in order to identify those patients at nutritional risk. The aim of this study was to determine the incidence and severity of PCM in these patients based on anthropometric, laboratory and immune status data. Methods: The nutrition assessment database was querried to determine the number of patients with an ICD 9 code (577.2) for CP who had been seen between 1983 and 1999. Nutrition assessment parameters included height, weight, usual body weight (UBW), ideal body weight (IBW), actual body weight (ABW), percent weight loss, body mass index (IBW), triceps skinfold (TSF), mid-upper arm muscle circumference (MUAMC), albulmin (ALB), transferrin (TFN), total lymphocyte count (TLC), response to delayed hypersensitivity skin tests (DHST), and prognostic nutrition index (PNI). Results are expressed as mean ⫹ SD. Results: 59 patients (21 females, 38 males) with a mean age of 49 ⫹ 4.3 years were identified. Ninety percent had evidence of PCM based on weight loss, BMI, anthropometry, serum ALB, and DHST. There was marked weight loss of 17% ⫹ 13%. The mean BMI was 19.66 ⫾ 3.95; TSF was 9 mm ⫾ 5; MUAMC was 21.5 cm ⫾ 3; serum ALB was 3.3 ⫾ 0.7. Eighty-six percent of the patients had DHST placed. Of these, 41% (n ⫽ 21) did not respond to skin tests, 39% (n ⫽ 20) responded to one skin test, 12% (n ⫽ 6) responded to two skin tests, 6% (n ⫽ 3) responded to three skin tests and 2% (n ⫽ 1) responded to all four skin tests. Mean transferrin levels was 201 ⫹ 81. The mean PNI was 35 ⫹ 31. Conclusions: Patients with CP are at increased risk of PCM. We identified 90% incidence of PCM in patients with CP admitted to a tertiary care setting. Further prospective investigations are needed to evaluate the consequences associated with this degree of PCM.
Center
1
Total 380 ERCP Grade 1 87 (%) Grade 2 9 (%) Grade 3 4 (%) Level of Procedure Difficulty Grade 1 Diagnostic ERCP
Abstracts
2
3
4
5
6
7
Total
928
3878
405
778
736
751
8094
91
37
72
77
82
73
60
7
11
22
11
9
14
11
3
52
7
11
9
13
29
Success Procedure Success Procedure % (n) % (n) 94 Standard 97 Stone (2342) sphincterotomy (2154) extraction 7) 69 Stone extraction 61 (63) (1087) ([gt10mm)]
Grade 2 Minor papilla cannulation Grade 3 Diagnostic 60 (20) Manometry ERCP in Roux-en-Y/ whipple’s
Success Procedure Success % (n) % (n) 87 Biliary 97 (937) Stents (1431)
87 (1203)Intrahepatic 50 (58) Pancreatic 73 (66) stone stone extraction extraction
237 Endoscopic management of primary sclerosing cholangitis (PSC) results in slowing of disease progression Mahadevan MD Uma, Bass MD Nathan, Ostroff MD James. University of California, San Francisco. Purpose: The effect of endoscopic intervention on the progression of PSC was studied. Methods: Endoscopic Retrograde Cholangiopancreatography (ERCP) was employed for diagnosis and therapy in PSC patients with jaundice, pruritis, sepsis or liver failure as a bridge to transplantation. Endoscopic sphincterotomy and balloon dilation without stent placement was used in symptomatic patients with multifocal PSC with extrahepatic and intrahepatic strictures. Dilation was attempted to secondary branches of the right and left lobe and dominant extrahepatic strictures with 4 – 6 mm dilating balloons. From 1992–1999, PSC patients who underwent ERCP with balloon dilation were compared with PSC patients awaiting transplantation who did not undergo therapeutic intervention. The endpoints were liver transplant, death, Child-Pugh score and the modified Mayo score. Rates of change in scores were compared using the Mann-Whitney test. Results: Patient characteristics are listed in the table. 17 patients underwent 127 ERCP’s with dilation. 1 episode of pancreatitis occurred. There were no procedure-related perforations or episodes of cholangitis. There were 5 transplants in the dilated group and 1 in the nondilated group. There was 1 death in the dilated group and 3 deaths in the nondilated group. There was a trend toward slower disease progression in the dilated group. The mean change and mean rate of change per year in the Child’s score was 0.53 vs. 1.67 (p ⫽ .41) and ⫺0.79 vs. 2.30 (p ⫽ .46) for the dilated and nondilated groups respectively. The mean change and mean rate of change per year in Mayo score was .13 vs. .61 (p ⫽ .36) and ⫺1.37 vs. 0.63 (p ⫽ .48) for the dilated and nondilated groups respectively. Conclusion: ERCP with balloon dilation and without endoprosthesis usage is a safe procedure in patients with advanced PSC. Periodic dilation may slow disease progression in these patients.
Dilated Nondil.
n
Mean age
M:F
IBD (%)
Mean duration PSC
17 9
45 45
9:8 8:1
88 78
6.2 4.9
Mean bilirubin (mg/dl)
Mean follow up (mos)
Follow up range (mos)
4.8 5.6
11.8 18.2
1–36 5–40
238 Primary pancreatic lymphoma diagnosed by endoscopic ultrasound Mann MD FACG SK, Condon MD D, Mann MD FACG NS, Leung MD FACG JW. VA Medical Center, Univ of Calif, Davis Medical Center, Sacramento.
2481
Primary pancreatic lymphoma (PPL) which originates and remains localized to pancreas is very rare (Pancreas 7:1118, 1992). Without histelogic examination, it cannot be differentiated from pancreatic carcinoma; the differentiation is important as treatment and prognosis are different. US, CAT and ERCP findings are not pathognomonic. Rarer still is PPL presenting as acute pancreatitis (AP) (Gastroenteral Clin Biol 23:528, 1999). We present a case of PPL which presented as AP and was diagnosed by EUS ⫹ FNA. Case Report: 78 year old male developed abdominal pain and had the clinical and biochemical criteria of AP CAT abdomen and US abdomen were unhelpful. ERCP showed a filling defect in the main pancreatic duct without ductal dilation, and impression was pancreatic carcinoma and pancreatic stent was placed with symptomatic improvement. EUS and FNA was performed to obtain histalogic diagnosis. EUS-FNA showed large B-cell non-hodgkin lymphoma. Extensive work up and bone-marrow showed no evidence of lymphoma at any other site. Radiotherapy and chemotherapy resulted in symptomatic relief; follow up EUS showed regression of PPL but not complete resolution. Discussion: PPL especially presenting as AP is very rare. CAT and US findings are not pathognomonic and may be similar to pancreatic carcimona. Differentiation is important as the treatment and prognosis are different. Conclusion: EUS-FNA was successfully used to diagnose a case of PPL which presented as AP.
239 Nutritional status of patients with chronic pancreatitis admitted to a tertiary care center Matarese RD Laura E, Conwell MD* Darwin L, Seidner MD Douglas L, Zuccaro MD Gregory, Steiger MD Ezra. The Cleveland Clinic Foundation, Cleveland, Ohio, United States. Purpose: Patients with chronic pancreatitis (CP) are at increased risk of developing protein calorie malnutrition (PCM) due to pancreatic insufficiency and inadequate oral intake due to post prandial pain. It is important to assess the nutritional status of these patients in order to identify those patients at nutritional risk. The aim of this study was to determine the incidence and severity of PCM in these patients based on anthropometric, laboratory and immune status data. Methods: The nutrition assessment database was querried to determine the number of patients with an ICD 9 code (577.2) for CP who had been seen between 1983 and 1999. Nutrition assessment parameters included height, weight, usual body weight (UBW), ideal body weight (IBW), actual body weight (ABW), percent weight loss, body mass index (IBW), triceps skinfold (TSF), mid-upper arm muscle circumference (MUAMC), albulmin (ALB), transferrin (TFN), total lymphocyte count (TLC), response to delayed hypersensitivity skin tests (DHST), and prognostic nutrition index (PNI). Results are expressed as mean ⫹ SD. Results: 59 patients (21 females, 38 males) with a mean age of 49 ⫹ 4.3 years were identified. Ninety percent had evidence of PCM based on weight loss, BMI, anthropometry, serum ALB, and DHST. There was marked weight loss of 17% ⫹ 13%. The mean BMI was 19.66 ⫾ 3.95; TSF was 9 mm ⫾ 5; MUAMC was 21.5 cm ⫾ 3; serum ALB was 3.3 ⫾ 0.7. Eighty-six percent of the patients had DHST placed. Of these, 41% (n ⫽ 21) did not respond to skin tests, 39% (n ⫽ 20) responded to one skin test, 12% (n ⫽ 6) responded to two skin tests, 6% (n ⫽ 3) responded to three skin tests and 2% (n ⫽ 1) responded to all four skin tests. Mean transferrin levels was 201 ⫹ 81. The mean PNI was 35 ⫹ 31. Conclusions: Patients with CP are at increased risk of PCM. We identified 90% incidence of PCM in patients with CP admitted to a tertiary care setting. Further prospective investigations are needed to evaluate the consequences associated with this degree of PCM.