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Patients with Primary Sclerosing Cholangitis Undergoing ERCP are at Increased Risk for Pancreatitis: Rectal Indomethacin Significantly Reduces the Risk
Comparison of Post-ERCP Pancreatitis Rates in all Patients undergoing ERCP and Patients with PSC.
293 A RANDOMIZED CONTROLLED TRIAL OF PROTON PUMP INHIBITORS IN THE TREATMENT OF ACUTE PANCREATITIS PATIENTS: THE BENEFITS AND HARMS Xiao Ma, Ling Liu, Huan Tong, Shihang Tang, Cheng Ye, Yang Tai, Chengwei Tang Background: Proton pump inhibitors (PPIs) are widely used in acute pancreatitis (AP) for its indirect inhibition of pancreatic secretion and the prevention of stress ulcer. Besides, previous studies have shown that anti-acid therapy with PPIs might increase the incidence of small intestinal bacteria overgrowth (SIBO), which has negative effect on the prognosis of acute pancreatitis. However, there is limited evidence for the anti-acid therapy in AP. Objective: This prospective randomized study was designed to evaluate the association between the use of PPIs and SIBO incidence in patients with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), and the anti-acid effect of PPIs was also investigated. Methods: 50 patients meeting the inclusion criteria were enrolled in this study from 2015 October to 2016 October (MSAP: n=8; SAP: n=42). Patients were randomly assigned into two groups, the PPIs group (n=26, conventional treatment plus esomeprazole 40 mg/day intravenously) and the non-PPIs (n=24) group, conventional treatment without PPIs). Duodenal aspirates for SIBO, gastric pH and upper gastrointestinal manifestation were obtained by endoscopy on 7th day of hospitalization. Duodenal aspirates were taken to microbiology lab for aerobic and anaerobic culture, and bacterial growth >105 CFU/mL was considered to be the evidence of SIBO. In addition, the fecal occult blood was analyzed. Results: The baseline characteristics of the PPIs group and the non-PPIs group were comparable. The gastric pH was remarkably higher in the PPIs group, comparing to the Non-PPIs group (4.51±2.21 vs.2.74±1.00, P<0.001). Both the SIBO incidence of the aerobic bacteria and the anaerobic culture were significantly increased in the PPIs group (aerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 25%, P=0.005; anaerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 20.8%, P=0.002). There were no significant differences of the peptic ulcer incidence and fecal occult blood positivity between two groups (peptic ulcer: PPIs vs. non-PPIs 3.7% vs. 11.5% P=0.351; positive fecal occult blood: PPIs vs. non-PPIs 40.7% vs. 26.9% P=0.387). Besides, the fungal esophagitis was observed only in the PPIs group (PPIs vs. non-PPIs: 18.5% vs.0, P=0.028). Conclusions: PPIs cannot effectively decrease the occurrence of peptic ulcer and gastrointestinal hemorrhage in patients with MSAP and SAP. Furthermore, PPIs is associated with more SIBO and fungal esophagitis in these patients, and these sideeffects should be highly concerned.
Trends in hospitalization, inpatient mortality, lenght of stay and cost of hospitalization.
Multivariate logistic regression analysis for predictors of mortality and AKI.
292 PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS UNDERGOING ERCP ARE AT INCREASED RISK FOR PANCREATITIS: RECTAL INDOMETHACIN SIGNIFICANTLY REDUCES THE RISK Nikhil Thiruvengadam, Kimberly A. Forde, Vinay Chandrasekhara, Michael L. Kochman
294 THE EFFECT OF NATIONWIDE COLORECTAL CANCER SCREENING ON COLORECTAL CANCER INCIDENCE AND MORTALITY: A 30-YEAR CHRONOLOGICAL STUDY Yi-Chia Lee, ChenYang Hsu, Tsung-Hsien Chiang, Chu-kuang Chou, Han-Mo Chiu, Ming-Shiang Wu
Background ERCP is utilized in primary sclerosing cholangitis (PSC) patients with strictures and for evaluation of cholangiocarcinoma. Adverse events occur; however the risk of postERCP pancreatitis (PEP) has not been well defined. The benefit of PEP prophylaxis with rectal indomethacin is unclear in this population. The objective of this study was to determine the risk of PEP in PSC patients and the effect of rectal indomethacin on rate and severity of PEP. Methods We conducted a retrospective cohort study in 4545 ERCP patients, 200 with PSC, at the Hospital of the University of Pennsylvania between January 1, 2008 and December 31, 2015. After June 2012, 100 mg rectal indomethacin was routinely administered. Incidence of PEP, determined by the Cotton criteria, was the primary outcome and development of moderate to severe PEP was the secondary outcome. All patients were contacted within 48-72 hours of their procedure. Comparison of baseline characteristics and multivariable logistic regression modeling, with adjustment for confounders, was used to determine the risk of PEP in PSC patients and the association between indomethacin and the primary and secondary outcomes. Results Of the 200 patients with PSC, 13 (6.5%) developed PEP. The 92 patients who received indomethacin and 108 who were unexposed were significantly different with respect to age, common bile duct (CBD) brushing and type of anesthesia administered. 1.08% and 11.01% of PSC patients in the indomethacin exposed and unexposed cohorts, respectively, developed PEP. (Figure 1) In PSC patients who had a sphincterotomy performed during prior ERCP, 10% in the unexposed cohort developed PEP. After adjustment for other important risk factors, PSC was independently associated with PEP (OR 2.71, 95% CI 1.37 - 5.40, p<0.001) in the larger cohort. After adjustment for CBD brushing, dilatation and type of sedation administered, indomethacin significantly reduced the risk of PEP (OR 0.10, 95% CI 0.02 - 0.78, p<0.001) in PSC patients. For the secondary outcome, no patients in the indomethacin group developed moderate to severe PEP (0% vs. 8%, p=0.002). Discussion: In this retrospective cohort study, we demonstrated: 1. Patients with PSC and particularly those with a prior history sphincterotomy have a high rate of post-ERCP pancreatitis. 2. Rectal indomethacin significantly decreased the rates of PEP and moderate to severe pancreatitis. 3. These data suggest that PSC patients may have an elevated risk for PEP independent of sphincterotomy performed during prior ERCP, which may not reduce the risk during subsequent ERCP. 4. PSC patients may benefit from routine usage of rectal indomethacin following ERCP.
Objective: To evaluate the impact of Nationwide Colorectal Cancer Screening (NCCS) on the incidence and mortality of colorectal cancer (CRC) in Taiwan. Methods: Data on numbers of incident CRC and death from CRC were retrieved from National Cancer Registry from 1984 to 2013. Among 335 million person-years of follow-up (aged 30 years or more), 204,362 incident CRCs and 80,771 CRC-related deaths were observed. We separated the observation time into three periods (1984-1993, 1994-2003, and 2004-2013) to respectively indicate the implementation of a nationwide health insurance coverage (starting 1994) and NCCS (starting 2004). Because only subjects aged 50-69 years were eligible for NCCS with biennial fecal immunochemical testing, we separated population into three age groups (3049, 50-69, and 70-84 years). We applied the Poisson regression model to investigate the effect of NCCS on the time trends of CRC incidence and mortality, adjusting for the age and sex. The results were expressed with the relative risk (RR) and 95% CI. Results: The mean incidence rates for the periods of 1984-1993, 1994-2003, and 2004-2013 were 30.63, 55.57, and 84.36/100,000 person-years, respectively, and the corresponding mortality rates were 16.77, 24.32, and 28.47/100,000 person-years, indicating increasing trends throughout the study period. Male gender had a 32.1% increased risk for CRC and a 38.6% increased risk for CRC death, compared with those of female. In multivariate analyses, the period effect was statistically significant on both the incidence and mortality while the interactions between period and age and between period and sex were statistically significant. Using 1984-1993 as the baseline comparator, stratified analyses showed that the RRs (95% CIs) of CRC incidence during the period of 1994-2003 were 1.56 (1.51-1.62), 1.71 (1.68-1.74), and 2.01 (1.95-2.06), respectively, for the age groups of 30-49, 50-69, and 70-84; the corresponding figures for the period of 2004-2013 were 2.27 (2.20-2.35), 2.21 (2.17-2.25), and 2.81 (2.74-2.88). Regarding mortality, the respective RRs were 1.24 (1.18-1.32), 1.41 (1.37-1.44), and 1.51 (1.45-1.57) for 1994-2003, and 1.43 (1.36-1.51), 1.30 (1.27-1.33), and 1.64 (1.57-1.70) for 2004-2013. Only in the age group of 50-69, a significantly reduced mortality of 7.4% (1 minus 1.30/1.41, 95% CI: 5.5-9.3%) was noted during 2004-2013 as
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AGA Abstracts
AGA Abstracts
during the study period, in spite of increasing hospitalizations and AKI rate. AP continues to be a significant economic burden to healthcare. Respiratory failure and septic shock are strongest predictors of AKI and inpatient mortality. AKI is independently associated with higher mortality and prolonged LOS with increasing hospitalization costs.
293 A RANDOMIZED CONTROLLED TRIAL OF PROTON PUMP INHIBITORS IN THE TREATMENT OF ACUTE PANCREATITIS PATIENTS: THE BENEFITS AND HARMS Xiao Ma, Ling Liu, Huan Tong, Shihang Tang, Cheng Ye, Yang Tai, Chengwei Tang Background: Proton pump inhibitors (PPIs) are widely used in acute pancreatitis (AP) for its indirect inhibition of pancreatic secretion and the prevention of stress ulcer. Besides, previous studies have shown that anti-acid therapy with PPIs might increase the incidence of small intestinal bacteria overgrowth (SIBO), which has negative effect on the prognosis of acute pancreatitis. However, there is limited evidence for the anti-acid therapy in AP. Objective: This prospective randomized study was designed to evaluate the association between the use of PPIs and SIBO incidence in patients with moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), and the anti-acid effect of PPIs was also investigated. Methods: 50 patients meeting the inclusion criteria were enrolled in this study from 2015 October to 2016 October (MSAP: n=8; SAP: n=42). Patients were randomly assigned into two groups, the PPIs group (n=26, conventional treatment plus esomeprazole 40 mg/day intravenously) and the non-PPIs (n=24) group, conventional treatment without PPIs). Duodenal aspirates for SIBO, gastric pH and upper gastrointestinal manifestation were obtained by endoscopy on 7th day of hospitalization. Duodenal aspirates were taken to microbiology lab for aerobic and anaerobic culture, and bacterial growth >105 CFU/mL was considered to be the evidence of SIBO. In addition, the fecal occult blood was analyzed. Results: The baseline characteristics of the PPIs group and the non-PPIs group were comparable. The gastric pH was remarkably higher in the PPIs group, comparing to the Non-PPIs group (4.51±2.21 vs.2.74±1.00, P<0.001). Both the SIBO incidence of the aerobic bacteria and the anaerobic culture were significantly increased in the PPIs group (aerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 25%, P=0.005; anaerobic bacteria: PPIs vs. non-PPIs 61.5% vs. 20.8%, P=0.002). There were no significant differences of the peptic ulcer incidence and fecal occult blood positivity between two groups (peptic ulcer: PPIs vs. non-PPIs 3.7% vs. 11.5% P=0.351; positive fecal occult blood: PPIs vs. non-PPIs 40.7% vs. 26.9% P=0.387). Besides, the fungal esophagitis was observed only in the PPIs group (PPIs vs. non-PPIs: 18.5% vs.0, P=0.028). Conclusions: PPIs cannot effectively decrease the occurrence of peptic ulcer and gastrointestinal hemorrhage in patients with MSAP and SAP. Furthermore, PPIs is associated with more SIBO and fungal esophagitis in these patients, and these sideeffects should be highly concerned.
Trends in hospitalization, inpatient mortality, lenght of stay and cost of hospitalization.
Multivariate logistic regression analysis for predictors of mortality and AKI.
292 PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS UNDERGOING ERCP ARE AT INCREASED RISK FOR PANCREATITIS: RECTAL INDOMETHACIN SIGNIFICANTLY REDUCES THE RISK Nikhil Thiruvengadam, Kimberly A. Forde, Vinay Chandrasekhara, Michael L. Kochman
294 THE EFFECT OF NATIONWIDE COLORECTAL CANCER SCREENING ON COLORECTAL CANCER INCIDENCE AND MORTALITY: A 30-YEAR CHRONOLOGICAL STUDY Yi-Chia Lee, ChenYang Hsu, Tsung-Hsien Chiang, Chu-kuang Chou, Han-Mo Chiu, Ming-Shiang Wu
Background ERCP is utilized in primary sclerosing cholangitis (PSC) patients with strictures and for evaluation of cholangiocarcinoma. Adverse events occur; however the risk of postERCP pancreatitis (PEP) has not been well defined. The benefit of PEP prophylaxis with rectal indomethacin is unclear in this population. The objective of this study was to determine the risk of PEP in PSC patients and the effect of rectal indomethacin on rate and severity of PEP. Methods We conducted a retrospective cohort study in 4545 ERCP patients, 200 with PSC, at the Hospital of the University of Pennsylvania between January 1, 2008 and December 31, 2015. After June 2012, 100 mg rectal indomethacin was routinely administered. Incidence of PEP, determined by the Cotton criteria, was the primary outcome and development of moderate to severe PEP was the secondary outcome. All patients were contacted within 48-72 hours of their procedure. Comparison of baseline characteristics and multivariable logistic regression modeling, with adjustment for confounders, was used to determine the risk of PEP in PSC patients and the association between indomethacin and the primary and secondary outcomes. Results Of the 200 patients with PSC, 13 (6.5%) developed PEP. The 92 patients who received indomethacin and 108 who were unexposed were significantly different with respect to age, common bile duct (CBD) brushing and type of anesthesia administered. 1.08% and 11.01% of PSC patients in the indomethacin exposed and unexposed cohorts, respectively, developed PEP. (Figure 1) In PSC patients who had a sphincterotomy performed during prior ERCP, 10% in the unexposed cohort developed PEP. After adjustment for other important risk factors, PSC was independently associated with PEP (OR 2.71, 95% CI 1.37 - 5.40, p<0.001) in the larger cohort. After adjustment for CBD brushing, dilatation and type of sedation administered, indomethacin significantly reduced the risk of PEP (OR 0.10, 95% CI 0.02 - 0.78, p<0.001) in PSC patients. For the secondary outcome, no patients in the indomethacin group developed moderate to severe PEP (0% vs. 8%, p=0.002). Discussion: In this retrospective cohort study, we demonstrated: 1. Patients with PSC and particularly those with a prior history sphincterotomy have a high rate of post-ERCP pancreatitis. 2. Rectal indomethacin significantly decreased the rates of PEP and moderate to severe pancreatitis. 3. These data suggest that PSC patients may have an elevated risk for PEP independent of sphincterotomy performed during prior ERCP, which may not reduce the risk during subsequent ERCP. 4. PSC patients may benefit from routine usage of rectal indomethacin following ERCP.
Objective: To evaluate the impact of Nationwide Colorectal Cancer Screening (NCCS) on the incidence and mortality of colorectal cancer (CRC) in Taiwan. Methods: Data on numbers of incident CRC and death from CRC were retrieved from National Cancer Registry from 1984 to 2013. Among 335 million person-years of follow-up (aged 30 years or more), 204,362 incident CRCs and 80,771 CRC-related deaths were observed. We separated the observation time into three periods (1984-1993, 1994-2003, and 2004-2013) to respectively indicate the implementation of a nationwide health insurance coverage (starting 1994) and NCCS (starting 2004). Because only subjects aged 50-69 years were eligible for NCCS with biennial fecal immunochemical testing, we separated population into three age groups (3049, 50-69, and 70-84 years). We applied the Poisson regression model to investigate the effect of NCCS on the time trends of CRC incidence and mortality, adjusting for the age and sex. The results were expressed with the relative risk (RR) and 95% CI. Results: The mean incidence rates for the periods of 1984-1993, 1994-2003, and 2004-2013 were 30.63, 55.57, and 84.36/100,000 person-years, respectively, and the corresponding mortality rates were 16.77, 24.32, and 28.47/100,000 person-years, indicating increasing trends throughout the study period. Male gender had a 32.1% increased risk for CRC and a 38.6% increased risk for CRC death, compared with those of female. In multivariate analyses, the period effect was statistically significant on both the incidence and mortality while the interactions between period and age and between period and sex were statistically significant. Using 1984-1993 as the baseline comparator, stratified analyses showed that the RRs (95% CIs) of CRC incidence during the period of 1994-2003 were 1.56 (1.51-1.62), 1.71 (1.68-1.74), and 2.01 (1.95-2.06), respectively, for the age groups of 30-49, 50-69, and 70-84; the corresponding figures for the period of 2004-2013 were 2.27 (2.20-2.35), 2.21 (2.17-2.25), and 2.81 (2.74-2.88). Regarding mortality, the respective RRs were 1.24 (1.18-1.32), 1.41 (1.37-1.44), and 1.51 (1.45-1.57) for 1994-2003, and 1.43 (1.36-1.51), 1.30 (1.27-1.33), and 1.64 (1.57-1.70) for 2004-2013. Only in the age group of 50-69, a significantly reduced mortality of 7.4% (1 minus 1.30/1.41, 95% CI: 5.5-9.3%) was noted during 2004-2013 as
S-73
AGA Abstracts
AGA Abstracts
during the study period, in spite of increasing hospitalizations and AKI rate. AP continues to be a significant economic burden to healthcare. Respiratory failure and septic shock are strongest predictors of AKI and inpatient mortality. AKI is independently associated with higher mortality and prolonged LOS with increasing hospitalization costs.