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Sa1312 Management of Biliary Disease in Pregnancy: 10-Year Experience At a Single Academic Medical Center
Sa1311
Prospective Clinical Short and Long Term Study on Critically Ill Patients With Sclerosing Cholangitis (SC-CIP) Florian Gesele, Klaus Egger, Jürgen Wallner, Vinzenz Weingart, Jan Perras, Volker Bühren, Hans-Dieter Allescher
The Impact of Body Mass Index As Predictive Factor of Steatocholecystitis Jai Hoon Yoon, Dae Yong Kim, Kyoung Min Sohn, Gwang Ho Baik, Yeon Soo Kim, Ki Tae Suk, Jin-Bong Kim, Dong Joon Kim Background/Aims: Obesity is a chronic inflammatory condition and is strongly linked to raised levels of pro-inflammatory factors and may lead to fatty infiltration of multiple internal organs including gallbladder and liver, causing organ dysfunctions. Fatty infiltration of gallbladder leads to chronic inflammation such as cholecystitis and tissue damage. This study was performed to evaluate association of body mass index (BMI) between acute and chronic cholecystitis, cholecystitis and cholestrolosis. We investigated clinical implication of BMI as predictive factor of cholesterol associated cholesystitis. Methods: This retrospective study covered the period from January 2007 to December April 2011, We evaluated 1158 patients who had cholecystectomy. We excluded gallbladder cancer, adenomyomatosis, cholestrolosis without cholecystitis. Finally, we investigated data of total 1065 patients with cholecystitis. Laboratory test. and clinical data such as age, sex, BMI, height, weight and underlying diseases. We investigated retrospectively acute and chronic cholecystitis, cholesterol polyps, other gallbladder disease such as gallbladder cancer and adenomyomatosis according the histopatholic finding. Parameters included (a) acute inflammation (i.e. epithelial and stromal neutrophil infiltration), (b) chronic inflammation (mononuclear cell infiltration), (c) cholesterosis, (d) presence of cholesterol polyp. Results: There was a significant difference of BMI between the cholecystitis with cholesterolosis and without cholesterolosis (p = 0.001). In patients who had cholecystitis with cholesterolosis, average of BMI was 25.2 kg/m2, In cholecystitis without cholesterolosis, average of BMI was 24.3 kg/m2. Weight, systolic blood pressure, platelet count, glucose, triglyceride, LDL-cholesterol were different in above groups (p,0.05). However, there was no significant difference between acute and chronic cholecystitis according to BMI (p=0.05). Conclusions: BMI was associated with steatocholecystitis. However, we can not predict whether acute or chronic cholecystitise according to BMI. We suggest that BMI be used as one of predictive factors of steatocholecystitis in obese patients.
Secundary sclerosing cholangitis is an important clinical entity in critically ill patients (SCCIP) with severe polpyraumas and shock symptoms. Most current data come from transplant centers at the end stage of the disease. The aim of this study was to indentify all patients with SC-CIP, to characterize imaging modalities such as US,MS-CT,MRCP, EUS and ERC for the diagnosis and therapy (ERC). We included 57 patients (m=41, f=16, age median 53y) from a large Bavarian trauma center from 2/2005-11/2009 retrospective (n=28) and 12/2009 -11/2011 prospective (n=29). SC-CIP-diagnosis of all patients (n=57) was confirmed by ERC by typical bile duct changes and by extraction and histology of cast material. Underlying disorders were 26 (46%) intracerebral bleeding, 17 (30%) severe polytrauma with MOF, 10 (17%) with severe septic schock, 4 (7%) with severe burning . At admission all patients except one had a NACA score . 3 and a SOFA score of median 8 (63.5% of the patients . 7). Intensive care stay lasted 44 days (range 23-298 days). SOFA score further increased to 11 on day 4 of admission. Patients had normal liver enzymes and gGT (median 32 U/l ) and AP values at admission and on day 1-4 of ICU stay. There was a characteristic rise of gGT on day 6 (median 98 U/l) reaching maximum values on days 11-13 (median 669 U/l). AP showed a linear increase also starting on day 5, whereas liver enzymes and bilirubin in median increased gradually. Abdominal US initially showed no dilation of the external or internal bile ducts, but showed intraluminal reflexes. With time intrahepatic segmental dilatation occurred. EUS showed echodense material with typical double-linear contours, characterized as cast material by ERC. ERC was performed median on day 53 of the ICU stay. In 35 (60%) of the patients both sides of the biliary systems were affected, whereas in 23 patients only one side was affected. In all patients papillotomy was performed and cast material was removed when present, strictures of the main duct and both hepatici were balloon dilated, all patients received antibiotics. 51/57 patients (89%) were followed by routine follow up, readmission, telephone contact or questionnaire with a follow up of 34.7 month. 27 patients had a favorable (n=8) or stable course (n=19). 3 patients received LTX, 5 patients have a negative course of the liver disease being listed for LTX, 16 Patients died during follow up, 4/16 died as a consequence of the SC-CIP. In conclusion: This study describes in a prospective manner in a single center study the clinical signs, course and parameters of SC-CIP patients. Mandatory interventional ERC removed biliary casts and stricutes and determined a long term outcome (2,6 years) with a letality of 14.5%, LTX rate of 5.1% and listing for LTX of 8.6%. This study adds new important clinical information to the initial course of this disease.
Sa1312 Management of Biliary Disease in Pregnancy: 10-Year Experience At a Single Academic Medical Center Rajesh N. Keswani, Annapoorani Veerappan, Andrew J. Gawron Introduction: Pregnancy is an established risk factor for symptomatic gallstone disease. Management of biliary disease during pregnancy may be more challenging due to the desire to avoid interventions that may cause fetal harm. We report the overall experience and trends in pregnancy-related biliary disease at a single institution. Methods: We retrospectively analyzed all patients who sought medical care for suspected biliary disease during pregnancy at a large academic tertiary care institution over a 10-year period (2002-2012). Patients were identified by querying an electronic data repository for relevant clinical diagnoses (cholelithiasis, cholecystitis, choledocholithiasis, and pancreatitis), imaging (CT, MRI), and procedure (cholecystectomy, ERCP, and Cesarean section) codes. To evaluate for trends in management and outcomes, differences in use of imaging and procedures were compared between two 5-year time periods (5/2002-5/2007 and 6/2007-6/2012). Results: A total of 307 patients (median age 31y) sought medical attention for symptomatic biliary disease over the 10-year period, the majority of whom were admitted to the hospital (n=276, 89.9%). The majority of patients were Caucasian (39.1%) or Hispanic (32.6%). Thirty-one (10.1%) patients were treated for biliary pancreatitis and 74 patients (24.1%) had liver chemistry test elevations suspicious for bile duct obstruction. Twenty-seven patients (8.8%) underwent ERCP and 15 patients (4.9%) received a cholecystectomy during pregnancy. Of the patients who underwent cholecystectomy during pregnancy, 93.3% were performed in the second trimester. 72.1% of patients reached term during their pregnancy and an operative delivery (Cesarean section) was performed in 30.3% of pregnancies. There was a trend towards older age at presentation in the 2007-2012 time period (Table). There was also a trend towards decreased total hospitalization days during pregnancy for biliary disease. There was a significant decrease in CT scan use (12.0% to 4.7%, P=0.01) and a trend towards increased use of MRI. There was a decrease in the use of cholecystectomy during pregnancy between the 1st (10.9%) and 2nd (2.9%, P = 0.01) 5-year time periods with similar rates of postpartum cholecystectomy. Conclusions: Biliary disease remains a significant problem in pregnancy frequently requiring hospitalization. The use of imaging modalities has changed and significantly fewer cholecystectomies in pregnant patients have been performed in more recent years. The clinical impact of these trends requires further study. Management Trends in Biliary Disease During Pregnancy
Sa1310 Long-Term Outcomes of Hepatolithiasis After Treatment; Risk Factors for Incomplete Clearance and Recurrence of Stone Sang-Woo Cha, Eui Bae Kim, Hyun Jong Choi, Soung Won Jeong, Jae Young Jang, Jong Ho Moon, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim BACKGROUND/AIMS: Operative and nonoperative treatments such as hepatectomy, percutaneous transhepatic cholangioscopy (PTCS), or ERCP have usually been performed to remove hepatolithiasis. Although these treatments are performed, recurrence is frequent and makes problems such as progressive biliary stricture, liver atrophy, liver cirrhosis, and cholangiocarcinoma. The aim of this study was to evaluate the long-term outcomes of hepatolithiais after operative and nonoperative treatments and examine the risk factors for incomplete stone clearance and the recurrence of stones or cholangitis after treatments. METHODS: The records of all patients with hepatolithiasis who underwent operative and nonoperative treatment at the Soonchunhyang University Hospital, Seoul, Korea, between January 1971 and September 2012, were analysed retrospectively. RESULTS: Of 454 patients with hepatolithiasis, 290 underwent at least 2 years follow-up after hepatectomy (n = 11), PTCSL (n = 110), or ERCP (n = 69) treatment. After a mean follow-up period of 8.0 years (up to 37 years), Complete stone clearance was achieved in 86.5% of hepatectomy, 67.3% of PTCSL, and 65.2% of ERCP (p=0.001). stone recurrence was occurred in 27%(30/111) of hepatectomy, 32.7%(36/110) of PTCSL, and 47.8%(33/69) of ERCP (p=0.015). Also, stone recurrence was 80%(12/15) in incomplete stone clearance of hepatectomy, 50%(18/ 36) in incomplete of PTCSL, and 58.3(14/24) in incomplete of ERCP (p ,0.001). Secondary biliary cirrhosis was 33.3%(5/15) in incomplete stone clearance of hepatectomy, 19.4%(7/ 36) in incomplete of PTCSL, and 12.4%(3/24) in complete of ERCP (p=0.048). Nonoperative treatments, biliary cirrhosis, bilateral stone location, and type 4 hepatolithiasis were significant risk factors for incomplete stone clearance on multivariate analysis. In addition, recurrent stones and/or cholangitis were associated with residual stone, nonoperative therapy, biliary cirrhosis, and young age on multivariate analysis. The cumulative disease free times after treatment for intrahepatic duct stone are 17.1 years in hepatectomy group, 13.4 in PTCSL group, and 9.0 in peroral cholangioscopy (p ,0.001). CONCLUSIONS: Operative treatment was superior to other treatments for complete stone clearance and showed the lowest recurrent stone and/or cholangitis rates. Recurrence and biliary cirrhosis showed higher rates of incomplete stone clearance regardless of treatment methods. Significant risk factors for incomplete stone clearance after treatment were nonoperative treatments, biliary cirrhosis, bilateral stone location, and type 4 hepatolithiasis. Residual stones, nonoperative treatments, biliary cirrhosis, and old age were associated with recurrent stones and/or cholangitis after treatment.
S-259
AGA Abstracts
AGA Abstracts
Sa1309
Prospective Clinical Short and Long Term Study on Critically Ill Patients With Sclerosing Cholangitis (SC-CIP) Florian Gesele, Klaus Egger, Jürgen Wallner, Vinzenz Weingart, Jan Perras, Volker Bühren, Hans-Dieter Allescher
The Impact of Body Mass Index As Predictive Factor of Steatocholecystitis Jai Hoon Yoon, Dae Yong Kim, Kyoung Min Sohn, Gwang Ho Baik, Yeon Soo Kim, Ki Tae Suk, Jin-Bong Kim, Dong Joon Kim Background/Aims: Obesity is a chronic inflammatory condition and is strongly linked to raised levels of pro-inflammatory factors and may lead to fatty infiltration of multiple internal organs including gallbladder and liver, causing organ dysfunctions. Fatty infiltration of gallbladder leads to chronic inflammation such as cholecystitis and tissue damage. This study was performed to evaluate association of body mass index (BMI) between acute and chronic cholecystitis, cholecystitis and cholestrolosis. We investigated clinical implication of BMI as predictive factor of cholesterol associated cholesystitis. Methods: This retrospective study covered the period from January 2007 to December April 2011, We evaluated 1158 patients who had cholecystectomy. We excluded gallbladder cancer, adenomyomatosis, cholestrolosis without cholecystitis. Finally, we investigated data of total 1065 patients with cholecystitis. Laboratory test. and clinical data such as age, sex, BMI, height, weight and underlying diseases. We investigated retrospectively acute and chronic cholecystitis, cholesterol polyps, other gallbladder disease such as gallbladder cancer and adenomyomatosis according the histopatholic finding. Parameters included (a) acute inflammation (i.e. epithelial and stromal neutrophil infiltration), (b) chronic inflammation (mononuclear cell infiltration), (c) cholesterosis, (d) presence of cholesterol polyp. Results: There was a significant difference of BMI between the cholecystitis with cholesterolosis and without cholesterolosis (p = 0.001). In patients who had cholecystitis with cholesterolosis, average of BMI was 25.2 kg/m2, In cholecystitis without cholesterolosis, average of BMI was 24.3 kg/m2. Weight, systolic blood pressure, platelet count, glucose, triglyceride, LDL-cholesterol were different in above groups (p,0.05). However, there was no significant difference between acute and chronic cholecystitis according to BMI (p=0.05). Conclusions: BMI was associated with steatocholecystitis. However, we can not predict whether acute or chronic cholecystitise according to BMI. We suggest that BMI be used as one of predictive factors of steatocholecystitis in obese patients.
Secundary sclerosing cholangitis is an important clinical entity in critically ill patients (SCCIP) with severe polpyraumas and shock symptoms. Most current data come from transplant centers at the end stage of the disease. The aim of this study was to indentify all patients with SC-CIP, to characterize imaging modalities such as US,MS-CT,MRCP, EUS and ERC for the diagnosis and therapy (ERC). We included 57 patients (m=41, f=16, age median 53y) from a large Bavarian trauma center from 2/2005-11/2009 retrospective (n=28) and 12/2009 -11/2011 prospective (n=29). SC-CIP-diagnosis of all patients (n=57) was confirmed by ERC by typical bile duct changes and by extraction and histology of cast material. Underlying disorders were 26 (46%) intracerebral bleeding, 17 (30%) severe polytrauma with MOF, 10 (17%) with severe septic schock, 4 (7%) with severe burning . At admission all patients except one had a NACA score . 3 and a SOFA score of median 8 (63.5% of the patients . 7). Intensive care stay lasted 44 days (range 23-298 days). SOFA score further increased to 11 on day 4 of admission. Patients had normal liver enzymes and gGT (median 32 U/l ) and AP values at admission and on day 1-4 of ICU stay. There was a characteristic rise of gGT on day 6 (median 98 U/l) reaching maximum values on days 11-13 (median 669 U/l). AP showed a linear increase also starting on day 5, whereas liver enzymes and bilirubin in median increased gradually. Abdominal US initially showed no dilation of the external or internal bile ducts, but showed intraluminal reflexes. With time intrahepatic segmental dilatation occurred. EUS showed echodense material with typical double-linear contours, characterized as cast material by ERC. ERC was performed median on day 53 of the ICU stay. In 35 (60%) of the patients both sides of the biliary systems were affected, whereas in 23 patients only one side was affected. In all patients papillotomy was performed and cast material was removed when present, strictures of the main duct and both hepatici were balloon dilated, all patients received antibiotics. 51/57 patients (89%) were followed by routine follow up, readmission, telephone contact or questionnaire with a follow up of 34.7 month. 27 patients had a favorable (n=8) or stable course (n=19). 3 patients received LTX, 5 patients have a negative course of the liver disease being listed for LTX, 16 Patients died during follow up, 4/16 died as a consequence of the SC-CIP. In conclusion: This study describes in a prospective manner in a single center study the clinical signs, course and parameters of SC-CIP patients. Mandatory interventional ERC removed biliary casts and stricutes and determined a long term outcome (2,6 years) with a letality of 14.5%, LTX rate of 5.1% and listing for LTX of 8.6%. This study adds new important clinical information to the initial course of this disease.
Sa1312 Management of Biliary Disease in Pregnancy: 10-Year Experience At a Single Academic Medical Center Rajesh N. Keswani, Annapoorani Veerappan, Andrew J. Gawron Introduction: Pregnancy is an established risk factor for symptomatic gallstone disease. Management of biliary disease during pregnancy may be more challenging due to the desire to avoid interventions that may cause fetal harm. We report the overall experience and trends in pregnancy-related biliary disease at a single institution. Methods: We retrospectively analyzed all patients who sought medical care for suspected biliary disease during pregnancy at a large academic tertiary care institution over a 10-year period (2002-2012). Patients were identified by querying an electronic data repository for relevant clinical diagnoses (cholelithiasis, cholecystitis, choledocholithiasis, and pancreatitis), imaging (CT, MRI), and procedure (cholecystectomy, ERCP, and Cesarean section) codes. To evaluate for trends in management and outcomes, differences in use of imaging and procedures were compared between two 5-year time periods (5/2002-5/2007 and 6/2007-6/2012). Results: A total of 307 patients (median age 31y) sought medical attention for symptomatic biliary disease over the 10-year period, the majority of whom were admitted to the hospital (n=276, 89.9%). The majority of patients were Caucasian (39.1%) or Hispanic (32.6%). Thirty-one (10.1%) patients were treated for biliary pancreatitis and 74 patients (24.1%) had liver chemistry test elevations suspicious for bile duct obstruction. Twenty-seven patients (8.8%) underwent ERCP and 15 patients (4.9%) received a cholecystectomy during pregnancy. Of the patients who underwent cholecystectomy during pregnancy, 93.3% were performed in the second trimester. 72.1% of patients reached term during their pregnancy and an operative delivery (Cesarean section) was performed in 30.3% of pregnancies. There was a trend towards older age at presentation in the 2007-2012 time period (Table). There was also a trend towards decreased total hospitalization days during pregnancy for biliary disease. There was a significant decrease in CT scan use (12.0% to 4.7%, P=0.01) and a trend towards increased use of MRI. There was a decrease in the use of cholecystectomy during pregnancy between the 1st (10.9%) and 2nd (2.9%, P = 0.01) 5-year time periods with similar rates of postpartum cholecystectomy. Conclusions: Biliary disease remains a significant problem in pregnancy frequently requiring hospitalization. The use of imaging modalities has changed and significantly fewer cholecystectomies in pregnant patients have been performed in more recent years. The clinical impact of these trends requires further study. Management Trends in Biliary Disease During Pregnancy
Sa1310 Long-Term Outcomes of Hepatolithiasis After Treatment; Risk Factors for Incomplete Clearance and Recurrence of Stone Sang-Woo Cha, Eui Bae Kim, Hyun Jong Choi, Soung Won Jeong, Jae Young Jang, Jong Ho Moon, Young Deok Cho, Sang-Heum Park, Sun-Joo Kim BACKGROUND/AIMS: Operative and nonoperative treatments such as hepatectomy, percutaneous transhepatic cholangioscopy (PTCS), or ERCP have usually been performed to remove hepatolithiasis. Although these treatments are performed, recurrence is frequent and makes problems such as progressive biliary stricture, liver atrophy, liver cirrhosis, and cholangiocarcinoma. The aim of this study was to evaluate the long-term outcomes of hepatolithiais after operative and nonoperative treatments and examine the risk factors for incomplete stone clearance and the recurrence of stones or cholangitis after treatments. METHODS: The records of all patients with hepatolithiasis who underwent operative and nonoperative treatment at the Soonchunhyang University Hospital, Seoul, Korea, between January 1971 and September 2012, were analysed retrospectively. RESULTS: Of 454 patients with hepatolithiasis, 290 underwent at least 2 years follow-up after hepatectomy (n = 11), PTCSL (n = 110), or ERCP (n = 69) treatment. After a mean follow-up period of 8.0 years (up to 37 years), Complete stone clearance was achieved in 86.5% of hepatectomy, 67.3% of PTCSL, and 65.2% of ERCP (p=0.001). stone recurrence was occurred in 27%(30/111) of hepatectomy, 32.7%(36/110) of PTCSL, and 47.8%(33/69) of ERCP (p=0.015). Also, stone recurrence was 80%(12/15) in incomplete stone clearance of hepatectomy, 50%(18/ 36) in incomplete of PTCSL, and 58.3(14/24) in incomplete of ERCP (p ,0.001). Secondary biliary cirrhosis was 33.3%(5/15) in incomplete stone clearance of hepatectomy, 19.4%(7/ 36) in incomplete of PTCSL, and 12.4%(3/24) in complete of ERCP (p=0.048). Nonoperative treatments, biliary cirrhosis, bilateral stone location, and type 4 hepatolithiasis were significant risk factors for incomplete stone clearance on multivariate analysis. In addition, recurrent stones and/or cholangitis were associated with residual stone, nonoperative therapy, biliary cirrhosis, and young age on multivariate analysis. The cumulative disease free times after treatment for intrahepatic duct stone are 17.1 years in hepatectomy group, 13.4 in PTCSL group, and 9.0 in peroral cholangioscopy (p ,0.001). CONCLUSIONS: Operative treatment was superior to other treatments for complete stone clearance and showed the lowest recurrent stone and/or cholangitis rates. Recurrence and biliary cirrhosis showed higher rates of incomplete stone clearance regardless of treatment methods. Significant risk factors for incomplete stone clearance after treatment were nonoperative treatments, biliary cirrhosis, bilateral stone location, and type 4 hepatolithiasis. Residual stones, nonoperative treatments, biliary cirrhosis, and old age were associated with recurrent stones and/or cholangitis after treatment.
S-259
AGA Abstracts
AGA Abstracts
Sa1309