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Pancreatic Resections of Autoimmune Pancreatitis (AIP)
AGA Abstracts
(p<0.01) being 143.5±43.6 minutes as compared to 97.8±10.6 minutes in controls. OCTT was not significantly different in alcoholic vs idiopathic (138.9±43.7 vs 145.5±39.7, p= 0.684), calcific vs non-calcific pancreatitis (151.8±42.4 vs 131.5±39.9, p=0.217), CP with diabetes vs non-diabetes (146.3±50.1 vs 144.1±43.8, p=0.2067). SIBO was present in 4/56 (7.4%) CP patients all of whom had diabetes. OCTT in patients with SIBO (187.5±38.9 minutes) was significantly higher (p<0.01) as compared to non-SIBO patients (136.4±43.16 minutes). Conclusion: Patients with chronic pancreatitis have significantly delayed orocecal transit time and some of these patients especially diabetics' may develop SIBO.
than CP in children without PRSS1 mutations. 2. We should be aware of coexisting HP and other factors causing CP, as anatomic anomalies. Su2064 Pancreatic Resections of Autoimmune Pancreatitis (AIP) Ryan Law, XiuLi Liu, Matthew Walsh, Lisa Yerian, Shetal Shah, Tyler Stevens Introduction: AIP presents as diffuse gland enlargement or a focal mass which may mimic cancer. An appropriate suspicion of AIP may avoid resections and allow effective treatment with corticosteroids. Aim: Evaluate imaging, serology, and clinical elements of the HISORt criteria (Chari S, CGH 2006) in patients who underwent surgical resection for a pancreatic mass or painful chronic pancreatitis (CP) and in whom pathology revealed AIP. Methods: Our pathology database was queried for pancreatic resections with initial pathological diagnosis of AIP or CP with severe chronic inflammation and significant fibrosis. Paraffin-embedded specimens were stained for IgG4 and reviewed by two GI pathologists. AIP was confirmed based on lymphoplasmocytic infiltrate and obliterative phlebitis, with or withough positive IgG4 staining (≥10/hpf). When available, contrast CT and MRCP images were re-reviewed by an abdominal radiologist. Results: 18 pts (mean age 51 yrs, 13M/5F) underwent resection (8 Whipples; 10 Distals), and had histologically confirmed AIP. 13 pts had resection between 1991 and 2006 (pre-HISORt); 5 between 2006 and 2010. Resection was due to suspected cancer in 11 pts and for painful CP in 7 pts. A preoperative suspicion of AIP was raised in only 1 pt. Clinical presentation included jaundice in 6, abdominal pain in 16, acute pancreatitis in 10, weight-loss in 8, and diabetes in 5. Preoperative CA19-9 was mildly elevated in 4 pts (52167 U/L). Preoperative FNA performed and negative in 5 pts. HISORt Criteria: Histology: No pt had a preoperative core biopsy. The initial diagnosis based on the surgical path was AIP in only 6 pts: 4/5 (80%) after 2006 and 2/13 (15.4%) before 2006 (p=0.02). The remaining 12 pts were diagnosed with “usual” CP (IgG4 staining not done on the surgical resection). Imaging: Images available for re-review in 14/18 (12 had CT; 6 had MRCP; 4 had both). 7/14 (50%) had a mass or focal enlargement. More specific AIP findings (capsule like rim, diffuse enlargement, diffuse pancreatic duct narrowing) were present in only 3 pts. Serology: A preoperative serum IgG4 was obtained in only 1 pt (348 U/L). Other organ involvement (e.g. biliary) was present in 3 pts; other coexisting autoimmune diseases in 1 pt. Response to treatment: No pt received preoperative corticosteroids. Conclusions: These patients underwent surgical resection and missed the opportunity for a steroid trial for treatment of AIP. Reasons include: 1. Lack of “specific” AIP imaging findings in majority of cases and 2. Lack of appropriate preoperative workup (e.g. serum IgG4 or core biopsy). Even after resection, the pathological diagnosis of AIP was often missed. Clinical Implication: Increased awareness of AIP and attentive consideration of the HISORt criteria by gastroenterologists, surgeons, and pathologists will hopefully decrease unnecessary resections in the future.
Su2062 A Population Based Study on Hospitalizations for Chronic Pancreatitis (CP) Dhiraj Yadav, Venkata Muddana, Michael R. O'Connell Background: Population based data on CP in the United States are scarce. The available information on hospitalizations is based on non-unique patients. We determined the hospitalization rates for CP in Allegheny County, Pennsylvania. Methods: The Pennsylvania Health Care Cost Containment Council (PHC4) is an independent state agency authorized to collect data on all hospitalizations in Pennsylvania. We used the PHC4 dataset to identify all unique White and Black Allegheny County residents who received an inpatient discharge diagnosis of CP (either as primary or as concurrent diagnosis with acute pancreatitis [AP] or pancreatic pseudocyst) from 1996-2005. Patients with a prior diagnosis of CP (primary or secondary) from 1990-95 were excluded. Information on associated diagnosis codes for alcoholism at the time of or within 1 year prior to index hospitalization was noted. Information on AP, CP, alcohol related liver disease, delirium tremens during follow up (end of third quarter 2007) was also noted. Age-, sex- and race-adjusted hospitalization rates (overall, each year) per 100,000 population (adjusted to 2000 US population) were calculated using direct standardization. Results: During 1996-2005, 988 unique White or Black residents had an incident hospital admission for CP. The mean age was 54+/-18 years, 50% were male, 75% were White, and 32% had associated alcoholism codes. Patients with alcoholism codes were more likely to be male (74 vs. 38%, p<0.001) or Black (38% vs. 20%, p<0.001). In patients with no associated alcoholism codes during or within 1 year prior to index hospitalization, new detection of alcohol-related liver disease or delirium tremens codes during follow up were seen in only 10/672 (1.3%) patients. The hospitalization rates (Table 1) were significantly higher in Blacks compared with Whites (overall-2.4 times, with alcoholism codes-4 times, with no alcoholism codes-1.7 times). The hospitalization rates for CP with alcoholism codes were significantly higher, and those without alcoholism codes were significantly lower in males compared with females. Hospitalization rates did not change significantly during the study period. CP patients with alcoholism codes were more likely to be young or middle aged (80% between ages 35-65 years) while those without alcoholism codes were more likely to be elderly (40% were 65 years or older). The prevalence of concurrent AP (50 vs. 23%, p<0.001) or subsequent admissions for AP or CP (67 vs. 45%, p<0.001) were significantly higher in patients with alcoholism codes. Conclusion: Hospitalization rates for CP differ based on gender and race. No significant increase in the rates for hospitalization was seen during the study period. CP patients with alcoholism codes have more symptomatic disease indicated by a high prevalence of concurrent AP and repeat admission for pancreatitis. Table 1: CP Hospitalization rates (95% CI) per 100,000 population in Allegheny County, PA 1996-2005
Su2065 Distinguishing Autoimmune Pancreatitis From Pancreatic Cancer Based on the Pancreas Imaging Jae-uk Shin, Jong Kyun Lee, Shin Young Min, Kwang Min Kim, Kwang Hyuck Lee, Kyu Taek Lee, Young Kon Kim, Jae Hoon Lim Background: Differentiation of autoimmune pancreatitis(AIP) from pancreas cancer(PC) is important to avoid unnecessary surgery. Distinguishing them usually begins from imaging study because clinical symtoms of both disease are similar. The aim of this study was to compare important findings of various imaging study to help differentiation of both disease. Method: Radiological features(CT/MRI/ERCP/MRCP/PET) of 36 AIP patients and 36 patients with pancreatic cancer diagnosed at Samsung medical center from April 1995 to October 2010 were evaluated. Results: On the CT/MRI findings, diffuse pancreas enlargement(AIP vs PC: 56% vs 3%; p=0.000; sensitivy 56%, specificity 97%), capsule like rim(81% vs 0%; p=0.000; 81%, 100%), homogenous enhancement(78% vs 3%; p=0.000; 78%, 97%), absence of upstream MPD dilatation≥5mm(89% vs 31%; p=0.000; 89%, 69%) were significantly more frequent in patient with AIP. On the pancreatogram findings, narrowed MPD≥ 1/3 of pancreatic length(73% vs 17%; p=0.000; 73%, 83%), skipped lesion of MPD narrowing(23% vs 0%; p= 0.002; 23%, 100%), presence of side branches in narrowed portion of MPD(27% vs 0%; p=0.001; 27%, 100%) were significantly more frequent in patient with AIP. However, upstream MPD dilatation≥5mm(6% vs 53%; p=0.000; 8% vs 35%), MPD obstruction(8% vs 25%; p=0.014; 12%, 57%), narrowed MPD≤1/3 of pancreatic length(11% vs 53%; p=0.001; 15%, 41%) were significantly more frequent in patient with pancreatic cancer. On the cholangiogram findings, only smooth and straight type of intrapancreatic CBD stenosis(57% vs 28%,p=0.009; 57%, 72%) was significantly more frequent in patient with AIP. On the PETCT findings(AIP 11 patients vs PC 24 patients), there were no significant differences in mean SUVmax( AIP 4.66 vs PC 5.21; p=0.137), uptake shape(round, 40% vs 76%; longitudinal 60% vs 24%; p=0.106), and extrapancreatic lesions(p=0.191) between both disease group. Conclusion: Diffuse pancreas enlargement, capsule like rim, delayed homogenous enhancement of the CT/MRI imaging and narrowed MPD≥1/3 of pancreatic length, skipped lesion of MPD narrowing, presence of side branches in narrowed portion of MPD on the cholagiopancreatogram have high specificity, therefore those findings may have great power in differentiating AIP from pancreatic cancer.
Su2063 Hereditary Pancreatitis of Childhood - 20-Years Experience at a Single Institution Grzegorz Oracz, Jaroslaw Kierkus, Maciej Dadalski, Jerzy Socha, Jozef Ryzko Introduction: Recently an association between chronic pancreatitis (CP) and gene mutations was identified. Hereditary pancreatitis (HP) is rare in childhood. Because of the infrequent occurrence of this disease, the clinician may be unfamiliar with optimal diagnostic and management strategies. We review our experience over the past 20 years. The aim of our study was to evaluate the clinical aspects of HP in children. Methods: 168 children with CP, hospitalized since 1990 to 2010, were enrolled into the study. The medical records of these patients were reviewed for data on the presentation, diagnostic findings and endoscopic treatment. All children were screened for gene mutations predisposing for CP (PRSS1, CFTR, SPINK1). Results: PRSS1 gene mutations were found in 19 patients (11%) (11 girls and 8 boys; mean age 8 years, range: 2.7-16.2 years). We detected R122H/- in 11 patients, R122C/in 5 patients, N29I/- in 2 patients and E79K/- in 1 patient. In 3 patients with HP we found anatomic anomalies of pancreatic duct- pancreas divisum in 2 cases and ansa pancreatica in 1 case. In one patient we found SPINK1 mutation (N34S/-). Hyperlipidemia was found in one other patient. Family history was positive in all children with HP except one. There was no difference in age of the disease onset between HP group and non-HP group (8.03 years vs. 9.08 years; NS). In children with PRSS1 mutation ERCP had mean 2,60 Cambridge grade according to the Cambridge Classification System, vs. 1.60 in non-HP group, p<0.05. 13 patients with HP had calcifications in the imagine studies (72% vs. 31%, p<0.05). Therapeutic intervention, including both surgical and endoscopic intervention, was more frequent in the HP group (78% vs. 35%; p<0.05). Pancreatic duct stenting was done in 11 children with HP (61% vs. 26% in non-HP group; p<0.05). Extracorporeal shock wave lithotripsy (ESWL) was performed more frequent in HP group (28% vs. 3% in non-HP group; p<0.05). Conclusions: 1. Hereditary pancreatitis in children has worse clinical course
AGA Abstracts
Su2066 Natural Clinical Course of Histologically Proven Autoimmune Pancreatitis: Experience From a Single Institution Ryan Law, Lisa Yerian, Matthew Walsh, Shetal Shah, Tyler Stevens, XiuLi Liu Introduction: Autoimmune pancreatitis (AIP), a “necroinflammatory disease of the pancreas mediated by autoimmune mechanism and without obvious etiologies”, is a rare but increasingly recognized form of chronic pancreatitis (CP). However, its natural clinical course is not well known due to its rarity and most of patients reported in the recent literature were treated with corticosteroids which may have modified its clinical course. Aim: To evaluate the natural history of AIP in the absence of corticosteroid treatment. Methods: Our pathology
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(p<0.01) being 143.5±43.6 minutes as compared to 97.8±10.6 minutes in controls. OCTT was not significantly different in alcoholic vs idiopathic (138.9±43.7 vs 145.5±39.7, p= 0.684), calcific vs non-calcific pancreatitis (151.8±42.4 vs 131.5±39.9, p=0.217), CP with diabetes vs non-diabetes (146.3±50.1 vs 144.1±43.8, p=0.2067). SIBO was present in 4/56 (7.4%) CP patients all of whom had diabetes. OCTT in patients with SIBO (187.5±38.9 minutes) was significantly higher (p<0.01) as compared to non-SIBO patients (136.4±43.16 minutes). Conclusion: Patients with chronic pancreatitis have significantly delayed orocecal transit time and some of these patients especially diabetics' may develop SIBO.
than CP in children without PRSS1 mutations. 2. We should be aware of coexisting HP and other factors causing CP, as anatomic anomalies. Su2064 Pancreatic Resections of Autoimmune Pancreatitis (AIP) Ryan Law, XiuLi Liu, Matthew Walsh, Lisa Yerian, Shetal Shah, Tyler Stevens Introduction: AIP presents as diffuse gland enlargement or a focal mass which may mimic cancer. An appropriate suspicion of AIP may avoid resections and allow effective treatment with corticosteroids. Aim: Evaluate imaging, serology, and clinical elements of the HISORt criteria (Chari S, CGH 2006) in patients who underwent surgical resection for a pancreatic mass or painful chronic pancreatitis (CP) and in whom pathology revealed AIP. Methods: Our pathology database was queried for pancreatic resections with initial pathological diagnosis of AIP or CP with severe chronic inflammation and significant fibrosis. Paraffin-embedded specimens were stained for IgG4 and reviewed by two GI pathologists. AIP was confirmed based on lymphoplasmocytic infiltrate and obliterative phlebitis, with or withough positive IgG4 staining (≥10/hpf). When available, contrast CT and MRCP images were re-reviewed by an abdominal radiologist. Results: 18 pts (mean age 51 yrs, 13M/5F) underwent resection (8 Whipples; 10 Distals), and had histologically confirmed AIP. 13 pts had resection between 1991 and 2006 (pre-HISORt); 5 between 2006 and 2010. Resection was due to suspected cancer in 11 pts and for painful CP in 7 pts. A preoperative suspicion of AIP was raised in only 1 pt. Clinical presentation included jaundice in 6, abdominal pain in 16, acute pancreatitis in 10, weight-loss in 8, and diabetes in 5. Preoperative CA19-9 was mildly elevated in 4 pts (52167 U/L). Preoperative FNA performed and negative in 5 pts. HISORt Criteria: Histology: No pt had a preoperative core biopsy. The initial diagnosis based on the surgical path was AIP in only 6 pts: 4/5 (80%) after 2006 and 2/13 (15.4%) before 2006 (p=0.02). The remaining 12 pts were diagnosed with “usual” CP (IgG4 staining not done on the surgical resection). Imaging: Images available for re-review in 14/18 (12 had CT; 6 had MRCP; 4 had both). 7/14 (50%) had a mass or focal enlargement. More specific AIP findings (capsule like rim, diffuse enlargement, diffuse pancreatic duct narrowing) were present in only 3 pts. Serology: A preoperative serum IgG4 was obtained in only 1 pt (348 U/L). Other organ involvement (e.g. biliary) was present in 3 pts; other coexisting autoimmune diseases in 1 pt. Response to treatment: No pt received preoperative corticosteroids. Conclusions: These patients underwent surgical resection and missed the opportunity for a steroid trial for treatment of AIP. Reasons include: 1. Lack of “specific” AIP imaging findings in majority of cases and 2. Lack of appropriate preoperative workup (e.g. serum IgG4 or core biopsy). Even after resection, the pathological diagnosis of AIP was often missed. Clinical Implication: Increased awareness of AIP and attentive consideration of the HISORt criteria by gastroenterologists, surgeons, and pathologists will hopefully decrease unnecessary resections in the future.
Su2062 A Population Based Study on Hospitalizations for Chronic Pancreatitis (CP) Dhiraj Yadav, Venkata Muddana, Michael R. O'Connell Background: Population based data on CP in the United States are scarce. The available information on hospitalizations is based on non-unique patients. We determined the hospitalization rates for CP in Allegheny County, Pennsylvania. Methods: The Pennsylvania Health Care Cost Containment Council (PHC4) is an independent state agency authorized to collect data on all hospitalizations in Pennsylvania. We used the PHC4 dataset to identify all unique White and Black Allegheny County residents who received an inpatient discharge diagnosis of CP (either as primary or as concurrent diagnosis with acute pancreatitis [AP] or pancreatic pseudocyst) from 1996-2005. Patients with a prior diagnosis of CP (primary or secondary) from 1990-95 were excluded. Information on associated diagnosis codes for alcoholism at the time of or within 1 year prior to index hospitalization was noted. Information on AP, CP, alcohol related liver disease, delirium tremens during follow up (end of third quarter 2007) was also noted. Age-, sex- and race-adjusted hospitalization rates (overall, each year) per 100,000 population (adjusted to 2000 US population) were calculated using direct standardization. Results: During 1996-2005, 988 unique White or Black residents had an incident hospital admission for CP. The mean age was 54+/-18 years, 50% were male, 75% were White, and 32% had associated alcoholism codes. Patients with alcoholism codes were more likely to be male (74 vs. 38%, p<0.001) or Black (38% vs. 20%, p<0.001). In patients with no associated alcoholism codes during or within 1 year prior to index hospitalization, new detection of alcohol-related liver disease or delirium tremens codes during follow up were seen in only 10/672 (1.3%) patients. The hospitalization rates (Table 1) were significantly higher in Blacks compared with Whites (overall-2.4 times, with alcoholism codes-4 times, with no alcoholism codes-1.7 times). The hospitalization rates for CP with alcoholism codes were significantly higher, and those without alcoholism codes were significantly lower in males compared with females. Hospitalization rates did not change significantly during the study period. CP patients with alcoholism codes were more likely to be young or middle aged (80% between ages 35-65 years) while those without alcoholism codes were more likely to be elderly (40% were 65 years or older). The prevalence of concurrent AP (50 vs. 23%, p<0.001) or subsequent admissions for AP or CP (67 vs. 45%, p<0.001) were significantly higher in patients with alcoholism codes. Conclusion: Hospitalization rates for CP differ based on gender and race. No significant increase in the rates for hospitalization was seen during the study period. CP patients with alcoholism codes have more symptomatic disease indicated by a high prevalence of concurrent AP and repeat admission for pancreatitis. Table 1: CP Hospitalization rates (95% CI) per 100,000 population in Allegheny County, PA 1996-2005
Su2065 Distinguishing Autoimmune Pancreatitis From Pancreatic Cancer Based on the Pancreas Imaging Jae-uk Shin, Jong Kyun Lee, Shin Young Min, Kwang Min Kim, Kwang Hyuck Lee, Kyu Taek Lee, Young Kon Kim, Jae Hoon Lim Background: Differentiation of autoimmune pancreatitis(AIP) from pancreas cancer(PC) is important to avoid unnecessary surgery. Distinguishing them usually begins from imaging study because clinical symtoms of both disease are similar. The aim of this study was to compare important findings of various imaging study to help differentiation of both disease. Method: Radiological features(CT/MRI/ERCP/MRCP/PET) of 36 AIP patients and 36 patients with pancreatic cancer diagnosed at Samsung medical center from April 1995 to October 2010 were evaluated. Results: On the CT/MRI findings, diffuse pancreas enlargement(AIP vs PC: 56% vs 3%; p=0.000; sensitivy 56%, specificity 97%), capsule like rim(81% vs 0%; p=0.000; 81%, 100%), homogenous enhancement(78% vs 3%; p=0.000; 78%, 97%), absence of upstream MPD dilatation≥5mm(89% vs 31%; p=0.000; 89%, 69%) were significantly more frequent in patient with AIP. On the pancreatogram findings, narrowed MPD≥ 1/3 of pancreatic length(73% vs 17%; p=0.000; 73%, 83%), skipped lesion of MPD narrowing(23% vs 0%; p= 0.002; 23%, 100%), presence of side branches in narrowed portion of MPD(27% vs 0%; p=0.001; 27%, 100%) were significantly more frequent in patient with AIP. However, upstream MPD dilatation≥5mm(6% vs 53%; p=0.000; 8% vs 35%), MPD obstruction(8% vs 25%; p=0.014; 12%, 57%), narrowed MPD≤1/3 of pancreatic length(11% vs 53%; p=0.001; 15%, 41%) were significantly more frequent in patient with pancreatic cancer. On the cholangiogram findings, only smooth and straight type of intrapancreatic CBD stenosis(57% vs 28%,p=0.009; 57%, 72%) was significantly more frequent in patient with AIP. On the PETCT findings(AIP 11 patients vs PC 24 patients), there were no significant differences in mean SUVmax( AIP 4.66 vs PC 5.21; p=0.137), uptake shape(round, 40% vs 76%; longitudinal 60% vs 24%; p=0.106), and extrapancreatic lesions(p=0.191) between both disease group. Conclusion: Diffuse pancreas enlargement, capsule like rim, delayed homogenous enhancement of the CT/MRI imaging and narrowed MPD≥1/3 of pancreatic length, skipped lesion of MPD narrowing, presence of side branches in narrowed portion of MPD on the cholagiopancreatogram have high specificity, therefore those findings may have great power in differentiating AIP from pancreatic cancer.
Su2063 Hereditary Pancreatitis of Childhood - 20-Years Experience at a Single Institution Grzegorz Oracz, Jaroslaw Kierkus, Maciej Dadalski, Jerzy Socha, Jozef Ryzko Introduction: Recently an association between chronic pancreatitis (CP) and gene mutations was identified. Hereditary pancreatitis (HP) is rare in childhood. Because of the infrequent occurrence of this disease, the clinician may be unfamiliar with optimal diagnostic and management strategies. We review our experience over the past 20 years. The aim of our study was to evaluate the clinical aspects of HP in children. Methods: 168 children with CP, hospitalized since 1990 to 2010, were enrolled into the study. The medical records of these patients were reviewed for data on the presentation, diagnostic findings and endoscopic treatment. All children were screened for gene mutations predisposing for CP (PRSS1, CFTR, SPINK1). Results: PRSS1 gene mutations were found in 19 patients (11%) (11 girls and 8 boys; mean age 8 years, range: 2.7-16.2 years). We detected R122H/- in 11 patients, R122C/in 5 patients, N29I/- in 2 patients and E79K/- in 1 patient. In 3 patients with HP we found anatomic anomalies of pancreatic duct- pancreas divisum in 2 cases and ansa pancreatica in 1 case. In one patient we found SPINK1 mutation (N34S/-). Hyperlipidemia was found in one other patient. Family history was positive in all children with HP except one. There was no difference in age of the disease onset between HP group and non-HP group (8.03 years vs. 9.08 years; NS). In children with PRSS1 mutation ERCP had mean 2,60 Cambridge grade according to the Cambridge Classification System, vs. 1.60 in non-HP group, p<0.05. 13 patients with HP had calcifications in the imagine studies (72% vs. 31%, p<0.05). Therapeutic intervention, including both surgical and endoscopic intervention, was more frequent in the HP group (78% vs. 35%; p<0.05). Pancreatic duct stenting was done in 11 children with HP (61% vs. 26% in non-HP group; p<0.05). Extracorporeal shock wave lithotripsy (ESWL) was performed more frequent in HP group (28% vs. 3% in non-HP group; p<0.05). Conclusions: 1. Hereditary pancreatitis in children has worse clinical course
AGA Abstracts
Su2066 Natural Clinical Course of Histologically Proven Autoimmune Pancreatitis: Experience From a Single Institution Ryan Law, Lisa Yerian, Matthew Walsh, Shetal Shah, Tyler Stevens, XiuLi Liu Introduction: Autoimmune pancreatitis (AIP), a “necroinflammatory disease of the pancreas mediated by autoimmune mechanism and without obvious etiologies”, is a rare but increasingly recognized form of chronic pancreatitis (CP). However, its natural clinical course is not well known due to its rarity and most of patients reported in the recent literature were treated with corticosteroids which may have modified its clinical course. Aim: To evaluate the natural history of AIP in the absence of corticosteroid treatment. Methods: Our pathology
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