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Su1240 Magnetic Resonance Elastography (MRE) of the Pancreas, a Feasibility Study in Healthy Volunteers
AGA Abstracts
opioid use differed between high and low resource users. However, significantly more patients with higher RU had alcoholic pancreatitis (n=7; χ2= 4.82, P<0.05). Imaging studies of the pancreas were obtained in 97 of these 116 patients (235 CT, 28 MRCP, 37 abdominal ultrasound examinations, 20 endoscopic ultrasound examinations and 70 ERCP). Thirteen patients were responsible for 40.67% of the CT scans. The cumulative exposure diagnostic radiation was 23.3±3.0 mSv with 33 (28%) patients exceeding annual exposures of 20 mSv. The use of diagnostic testing was primarily influenced by disease-specific variables (etiology, disease duration and complications) with the presence of pseudocysts being the best predictor of CT use. Discussion: Patients with CP frequently require emergency care and hospitalization with a small subgroup being responsible for about half of the consumed resources. While diagnostic testing is largely driven by factors related to the biology of disease, psychosocial factors significantly contribute to emergency encounters and repeat hospitalizations, highlighting the need for comprehensive approaches to effectively manage these patients. Su1242 Clinical Significance of Serum IgG and IgG4 Levels for Evaluation of the Disease Activity in IgG4-Related Disease Nao Fujimori, Hisato Igarashi, Takamasa Oono, Taichi Nakamura, Yusuke Niina, Masayuki Hijioka, Lingaku Lee, Masahiko Uchida, Ryoichi Takayanagi, Tetsuhide Ito
Su1240 Magnetic Resonance Elastography (MRE) of the Pancreas, a Feasibility Study in Healthy Volunteers G. Anton Decker, Kevin J. Glaser, Laurence J. Miller, Rahul Pannala, Douglas O. Faigel, Cuong C. Nguyen, Joseph M. Collins, Richard L. Ehman, Alvin C. Silva
Background: Autoimmune pancreatitis (AIP) is recognized as a pancreatic lesion of IgG4related disease, which has recently attracted wide attention. Some researchers have suggested that serum levels of IgG and IgG4 are indicators for diagnosis and disease activity; however, the clinical significance of serum IgG and IgG4 is largely unknown. Methods: We retrospectively reviewed 52 patients with IgG4-related disease who were diagnosed in Kyushu University hospital between 2002 and 2011. Of the 52 patients, there were 47 patients accompanied with AIP and 5 patients were not involving in pancreatic lesions. To clarify the role of serum IgG and IgG4 in the disease activity of IgG4-related disease, we evaluated I) the relationship between the extent of inflammation and serum levels of IgG and IgG4 at initial diagnosis, and II) serial changes of serum IgG and IgG4 during follow-up of the disease. I) the number of lesions and serum IgG and IgG4 levels were examined in 46 patients (6 patients with serum IgG4<135mg/dL were excluded) with IgG4-related diseases at diagnosis prior to the initiation of steroid treatment. The relationship between serum IgG and IgG4 levels and the number of involved regions (i.e. AIP, sclerosing cholangitis, sialadenitis, retroperitoneal fibrosis, etc.) were examined by group: group A (1 region involved, n=7), group B (2 regions, n=11), group C (3 regions, n=12), group D (4 regions, n=9), and group E (5-7 regions, n= 7). II) Clinical features of relapsed patients including serial changes of serum IgG and IgG4 were evaluated. Relapse of disease was defined as the development or recurrence of pancreatic and/or extrapancreatic abnormalities by imaging studies. Results: I) Serum IgG levels increased as the number of involved regions increased, and were 1511, 1865, 2092, 2329, and 3259 mg/dL in group A, B, C, D, and E, respectively. The mean serum IgG4 levels in group A, B, C, D, and E, were 399, 470, 470, 986, and 1649 mg/dL, respectively, indicating that in patients with 5 or more regions involved, serum IgG4 levels were significantly higher compared to the levels in other groups. Regression analysis suggested that serum IgG (correlation coefficient, rho=0.58) and IgG4 (correlation coefficient, rho=0.61) were correlated with the number of involved regions. II) Relapse of disease was observed in 16 patients (31%), who were all AIP patients. In relapsed patients, serum IgG and IgG4 at remission were significantly lower compared with those at initial diagnosis (p<0.01). Furthermore, significant elevation of serum IgG and IgG4 at relapse was observed compared with those at remission (p<0.01), indicating that serial changes of serum IgG and IgG4 levels were correlated with the disease activity. Conclusion: These results suggest that serum IgG and IgG4 levels might be useful to determine the disease activity of IgG4-related disease.
Background: MRE is a non-invasive advanced imaging technique utilizing wave propagation to characterize the In Vivo mechanical properties of tissue, including stiffness, in organs such as the liver. MRE of the pancreas has not been thoroughly studied, but could provide a non-invasive tool for assessing pancreatic pathology such as pancreatitis, solid and cystic pancreatic masses. Aims: To determine the feasibility of MRE of the pancreas and establish normal ranges for tissue density of the normal pancreas. Methods: IRB approval was obtained. Stage 1: MRE of the pancreas was performed in 12 healthy volunteers with a 2-D gradientecho (GRE) sequence. An acoustic driver (AD) system delivered 40 HZ vibrations into the abdomen via a plastic drum secured via an elastic belt and powered pneumatically by a speaker located outside of the scan room. In an attempt to optimize wave propagation, the AD was placed over the liver, pancreas and left flank with the patient supine, and over the mid back with patient prone. MR elastograms were generated using an inversion algorithm to yield quantitative images of tissue stiffness in kilopascals (kPa). Stage 2: 3-D MRE was performed in 12 healthy volunteers using a flow-compensated single-shot spin-echo planar imaging (EPI) acquisition with motion encoding performed sequentially in the X, Y, and Z directions. Processing of the measured 3D displacement field was performed by first calculating the 3D vector curl of the displacement field and then using a 3D local frequency estimation (LFE) algorithm to calculate the tissue stiffness from the curl data. The pancreas was manually segmented using the MRE magnitude images and the mean stiffness in kilopascals (kPa) was recorded. Results: Stage 1: With the 2D MRE technique, there was poor pancreatic wave propagation at all AD locations - including patient supine and prone - for all 12 volunteers. This precluded accurate mean shear pancreatic stiffness calculation. Stage 2: With 3D MRE technique (image 1), 10 of 12 volunteers had adequate pancreatic wave propagation, with calculated mean shear hepatic stiffness of 1.04 ± 0.25 kPa (range 0.861.25 kPa). Of the 2 with poor wave propagation, one had BMI >30 kg/m2, and one had an atrophic pancreas. Conclusions: MRE of the pancreas is feasible, but requires 3D image sequencing to obtain adequate elastograms to calculate tissue stiffness. Further refinements in the technology are required to obtain consistent elastograms, including for patients with obesity or pancreatic atrophy. Ongoing investigations include determining the variation in stiffness within regions of the pancreas and to compare the normal pancreas with the spectrum of pancreatic diseases including pancreatic cancer, pancreatic cysts, acute and chronic pancreatitis.
Su1243 Rituximab Monotherapy is Effective for Treatment of Pancreaticobiliary Involvement in IgG4-Related Disease Phil Hart, Thomas Witzig, Mark Topazian, Robin Klebig, Jonathan E. Clain, Ferga C. Gleeson, Michael J. Levy, Randall K. Pearson, Thomas C. Smyrk, Bret T. Petersen, Naoki Takahashi, Santhi Swaroop Vege, Suresh T. Chari
Su1241 Chronic Pancreatitis: What Determines Resource Utilization? Salman Nusrat, Dhiraj Yadav, Klaus Bielefeldt
Introduction: IgG4-related disease (IgG4-RD) is a multi-organ syndrome characterized by typical histopathology, tissue infiltration by IgG4-positive cells, and frequent elevation of serum IgG4 levels. Pancreatic and biliary involvement in IgG4-RD are called autoimmune pancreatitis (AIP) and IgG4-associated cholangitis (IAC), respectively. An initial treatment response to steroids is invariable in IgG4-RD. Relapses are common following or during steroid withdrawal and can typically be managed with re-initiation of steroids or by increasing the dose. However, some patients either require high-dose steroids for maintenance or are intolerant of steroids. We report our experience using rituximab (RTX) for the management of patients with pancreaticobiliary involvement of IgG4-RD. Methods: All patients with AIP and/or IAC treated with RTX were included.Rituximab was administered in a standard protocol consisting of infusions of 375 mg/m2 for four weekly doses, followed by maintenance
Objective: Pain is the hallmark symptom of chronic pancreatitis (CP) and the main reason for physician visits and hospitalizations. We thus tested the hypothesis that pain severity correlates with resource utilization (RU). Methods: Records of patients with established pancreatitis seen at least twice between 4/2008 and 12/2009 at University of Pittsburgh Digestive Disorder Clinic were retrospectively reviewed. Results: During 123 patient-years of follow up in 116 patients, we recorded 187 emergency room visits (n=46 patients), 140 hospitalizations (n=51 patients) amounting to a total of 774 inpatients treatment days; 10 patients accounted for 51% of the inpatient days and only 5 patients were responsible for 54% of the emergency room visits. Neither subjective pain ratings nor the average daily
AGA Abstracts
S-458
opioid use differed between high and low resource users. However, significantly more patients with higher RU had alcoholic pancreatitis (n=7; χ2= 4.82, P<0.05). Imaging studies of the pancreas were obtained in 97 of these 116 patients (235 CT, 28 MRCP, 37 abdominal ultrasound examinations, 20 endoscopic ultrasound examinations and 70 ERCP). Thirteen patients were responsible for 40.67% of the CT scans. The cumulative exposure diagnostic radiation was 23.3±3.0 mSv with 33 (28%) patients exceeding annual exposures of 20 mSv. The use of diagnostic testing was primarily influenced by disease-specific variables (etiology, disease duration and complications) with the presence of pseudocysts being the best predictor of CT use. Discussion: Patients with CP frequently require emergency care and hospitalization with a small subgroup being responsible for about half of the consumed resources. While diagnostic testing is largely driven by factors related to the biology of disease, psychosocial factors significantly contribute to emergency encounters and repeat hospitalizations, highlighting the need for comprehensive approaches to effectively manage these patients. Su1242 Clinical Significance of Serum IgG and IgG4 Levels for Evaluation of the Disease Activity in IgG4-Related Disease Nao Fujimori, Hisato Igarashi, Takamasa Oono, Taichi Nakamura, Yusuke Niina, Masayuki Hijioka, Lingaku Lee, Masahiko Uchida, Ryoichi Takayanagi, Tetsuhide Ito
Su1240 Magnetic Resonance Elastography (MRE) of the Pancreas, a Feasibility Study in Healthy Volunteers G. Anton Decker, Kevin J. Glaser, Laurence J. Miller, Rahul Pannala, Douglas O. Faigel, Cuong C. Nguyen, Joseph M. Collins, Richard L. Ehman, Alvin C. Silva
Background: Autoimmune pancreatitis (AIP) is recognized as a pancreatic lesion of IgG4related disease, which has recently attracted wide attention. Some researchers have suggested that serum levels of IgG and IgG4 are indicators for diagnosis and disease activity; however, the clinical significance of serum IgG and IgG4 is largely unknown. Methods: We retrospectively reviewed 52 patients with IgG4-related disease who were diagnosed in Kyushu University hospital between 2002 and 2011. Of the 52 patients, there were 47 patients accompanied with AIP and 5 patients were not involving in pancreatic lesions. To clarify the role of serum IgG and IgG4 in the disease activity of IgG4-related disease, we evaluated I) the relationship between the extent of inflammation and serum levels of IgG and IgG4 at initial diagnosis, and II) serial changes of serum IgG and IgG4 during follow-up of the disease. I) the number of lesions and serum IgG and IgG4 levels were examined in 46 patients (6 patients with serum IgG4<135mg/dL were excluded) with IgG4-related diseases at diagnosis prior to the initiation of steroid treatment. The relationship between serum IgG and IgG4 levels and the number of involved regions (i.e. AIP, sclerosing cholangitis, sialadenitis, retroperitoneal fibrosis, etc.) were examined by group: group A (1 region involved, n=7), group B (2 regions, n=11), group C (3 regions, n=12), group D (4 regions, n=9), and group E (5-7 regions, n= 7). II) Clinical features of relapsed patients including serial changes of serum IgG and IgG4 were evaluated. Relapse of disease was defined as the development or recurrence of pancreatic and/or extrapancreatic abnormalities by imaging studies. Results: I) Serum IgG levels increased as the number of involved regions increased, and were 1511, 1865, 2092, 2329, and 3259 mg/dL in group A, B, C, D, and E, respectively. The mean serum IgG4 levels in group A, B, C, D, and E, were 399, 470, 470, 986, and 1649 mg/dL, respectively, indicating that in patients with 5 or more regions involved, serum IgG4 levels were significantly higher compared to the levels in other groups. Regression analysis suggested that serum IgG (correlation coefficient, rho=0.58) and IgG4 (correlation coefficient, rho=0.61) were correlated with the number of involved regions. II) Relapse of disease was observed in 16 patients (31%), who were all AIP patients. In relapsed patients, serum IgG and IgG4 at remission were significantly lower compared with those at initial diagnosis (p<0.01). Furthermore, significant elevation of serum IgG and IgG4 at relapse was observed compared with those at remission (p<0.01), indicating that serial changes of serum IgG and IgG4 levels were correlated with the disease activity. Conclusion: These results suggest that serum IgG and IgG4 levels might be useful to determine the disease activity of IgG4-related disease.
Background: MRE is a non-invasive advanced imaging technique utilizing wave propagation to characterize the In Vivo mechanical properties of tissue, including stiffness, in organs such as the liver. MRE of the pancreas has not been thoroughly studied, but could provide a non-invasive tool for assessing pancreatic pathology such as pancreatitis, solid and cystic pancreatic masses. Aims: To determine the feasibility of MRE of the pancreas and establish normal ranges for tissue density of the normal pancreas. Methods: IRB approval was obtained. Stage 1: MRE of the pancreas was performed in 12 healthy volunteers with a 2-D gradientecho (GRE) sequence. An acoustic driver (AD) system delivered 40 HZ vibrations into the abdomen via a plastic drum secured via an elastic belt and powered pneumatically by a speaker located outside of the scan room. In an attempt to optimize wave propagation, the AD was placed over the liver, pancreas and left flank with the patient supine, and over the mid back with patient prone. MR elastograms were generated using an inversion algorithm to yield quantitative images of tissue stiffness in kilopascals (kPa). Stage 2: 3-D MRE was performed in 12 healthy volunteers using a flow-compensated single-shot spin-echo planar imaging (EPI) acquisition with motion encoding performed sequentially in the X, Y, and Z directions. Processing of the measured 3D displacement field was performed by first calculating the 3D vector curl of the displacement field and then using a 3D local frequency estimation (LFE) algorithm to calculate the tissue stiffness from the curl data. The pancreas was manually segmented using the MRE magnitude images and the mean stiffness in kilopascals (kPa) was recorded. Results: Stage 1: With the 2D MRE technique, there was poor pancreatic wave propagation at all AD locations - including patient supine and prone - for all 12 volunteers. This precluded accurate mean shear pancreatic stiffness calculation. Stage 2: With 3D MRE technique (image 1), 10 of 12 volunteers had adequate pancreatic wave propagation, with calculated mean shear hepatic stiffness of 1.04 ± 0.25 kPa (range 0.861.25 kPa). Of the 2 with poor wave propagation, one had BMI >30 kg/m2, and one had an atrophic pancreas. Conclusions: MRE of the pancreas is feasible, but requires 3D image sequencing to obtain adequate elastograms to calculate tissue stiffness. Further refinements in the technology are required to obtain consistent elastograms, including for patients with obesity or pancreatic atrophy. Ongoing investigations include determining the variation in stiffness within regions of the pancreas and to compare the normal pancreas with the spectrum of pancreatic diseases including pancreatic cancer, pancreatic cysts, acute and chronic pancreatitis.
Su1243 Rituximab Monotherapy is Effective for Treatment of Pancreaticobiliary Involvement in IgG4-Related Disease Phil Hart, Thomas Witzig, Mark Topazian, Robin Klebig, Jonathan E. Clain, Ferga C. Gleeson, Michael J. Levy, Randall K. Pearson, Thomas C. Smyrk, Bret T. Petersen, Naoki Takahashi, Santhi Swaroop Vege, Suresh T. Chari
Su1241 Chronic Pancreatitis: What Determines Resource Utilization? Salman Nusrat, Dhiraj Yadav, Klaus Bielefeldt
Introduction: IgG4-related disease (IgG4-RD) is a multi-organ syndrome characterized by typical histopathology, tissue infiltration by IgG4-positive cells, and frequent elevation of serum IgG4 levels. Pancreatic and biliary involvement in IgG4-RD are called autoimmune pancreatitis (AIP) and IgG4-associated cholangitis (IAC), respectively. An initial treatment response to steroids is invariable in IgG4-RD. Relapses are common following or during steroid withdrawal and can typically be managed with re-initiation of steroids or by increasing the dose. However, some patients either require high-dose steroids for maintenance or are intolerant of steroids. We report our experience using rituximab (RTX) for the management of patients with pancreaticobiliary involvement of IgG4-RD. Methods: All patients with AIP and/or IAC treated with RTX were included.Rituximab was administered in a standard protocol consisting of infusions of 375 mg/m2 for four weekly doses, followed by maintenance
Objective: Pain is the hallmark symptom of chronic pancreatitis (CP) and the main reason for physician visits and hospitalizations. We thus tested the hypothesis that pain severity correlates with resource utilization (RU). Methods: Records of patients with established pancreatitis seen at least twice between 4/2008 and 12/2009 at University of Pittsburgh Digestive Disorder Clinic were retrospectively reviewed. Results: During 123 patient-years of follow up in 116 patients, we recorded 187 emergency room visits (n=46 patients), 140 hospitalizations (n=51 patients) amounting to a total of 774 inpatients treatment days; 10 patients accounted for 51% of the inpatient days and only 5 patients were responsible for 54% of the emergency room visits. Neither subjective pain ratings nor the average daily
AGA Abstracts
S-458