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Thrombosis of Splanchnic Veins During a First Episode of Acute Pancreatitis: Prevalence and Outcomes
Sa1332
Background & Aim: Thrombosis of Splanchnic Veins (TSV) is a potentially severe complication of acute pancreatitis. It most commonly affects the splanchnic, portal or superior mesenteric veins. Acute pancreatitis (AP) is the most common gastrointestinal discharge diagnosis in the United States. The aim of this single-center, retrospective cohort study was to investigate the incidence of TSV and to determine the connected risk factors and outcomes. Methods: We performed a retrospective cohort study of consecutive patients admitted with a very first episode of acute pancreatitis at a large public hospital between 01/2013 and 12/ 2014. We identified acute pancreatitis diagnosis by ICD9 code and/or lipase ≥ 3 times the normal upper limit. Two physicians reviewed each case to include only first episodes of acute pancreatitis. We excluded patients who were transferred to our center. We reviewed the abdominal CT scans with contrast from that admission to look for New thrombosis of the Splanchnic Veins. We constructed multivariable logistic regression models using STATA software version 13. Results: We analyzed 460 patients. Mean age was 48 years (range 17 to 89 years), 54% were males. Of 460 acute pancreatitis patients, 108 had an IV contrast enhanced abdominal CT scan. The prevalence of TSV was 6% (7 cases). According to the most common affected vessel we found: Portal vein (4 cases), Splenic vein (2 cases) and SMV (1 case). Only 1 of the 7 cases was anticoagulated; this case was the only death between the 7 cases. The prevalence of pancreatic necrosis was 19%, SIRS on admission was 31%, persistent SIRS at 48h was 19% and AKI was 24%. In Univariate analysis, Alcohol intake, male gender and smoking were found to be risk factors for TSV. In Multivariate analysis the only risk factor for TSV was smoking tobacco (aOR: 1.2, p<0.001; CI 1.1-1.4). We found that AKI was less common among patients without TSV when compared to the TSV group (OR: 0.2; p<0.05; CI 0.2-0.9). After adjusting for admission SIRS, age and gender; TSV was not found to be an independent risk factor for Persistent SIRS, AKI, ARDS, pancreatic necrosis, mortality, ICU, LOS, in-hospital infections, BISAP score, nor recurrent AP. In addition, no significant difference in the recanalization rates was found in those with and without AC (p=NS). Limitations: Retrospective study. Strength: Robust patient cohort. Absence of transferred patients. Conclusion: Thrombosis of Splanchnic Veins incidence was found to be low in our cohort when compared to the reported literature. Moreover, TSV was Not found to impact the outcomes of acute pancreatitis. Smoking should call the physician's attention on the risk of abdominal vein thrombosis in acute pancreatitis. Anticoagulation of abdominal vein thrombosis is still a controversy and no benefit was found in our cohort.
H&E Staining consistent with signet-ring cell carcinoma from pancreas
Left to right : CDX positive, Cytokeratin 20 positive, Cytokeratin 7 negative. This staining pattern would be quite unusual for a pancreatic neoplasm
Sa1330 ARE INTERLEUKINS USEFUL IN PREDICTING THE SEVERITY OF ACUTE PANCREATITIS? Davorin B. C´eranic´, Pavel Skok, Milan Zorman Introduction Severe acute pancreatitis (SAP) develops in 15-25% of patients this disease. Prediction of severity is crucial in clinical practice. Aims To evaluate the role of interleukins and inflammatory markers in a prospective study. Patients and methods Included were 96 patients with AP. Laboratory parameters were analyzed on admission, after 48 hours and during hospitalisation, daily. A binomial logistic regression was performed. Results In the study were 59 (61.5%) males and 37 (38.5%) females, average age 61.5±15.9 years. The etiology was identified as gallstones in 52 %, alcohol in 33 % and other causes in 14 % . Three patients (3%) died due to multi-organ failure. Interleukin-6 (IL-6) has the greatest predictive value in prediction of SAP at admission (AUC=0.78) and after 48 hours (AUC= 0.84). IL-8 (AUC=0.70); IL-10 (AUC=0.74) were also useful markers. In comparison between the values at admission and after 48 hours, CRP has been shown to have better predictive value at follow up (AUC=0.82). At cut-off value of 152, the sensitivity was 81.3% and specificity 68.8%. Useful predictors of SAP were also LDH (p<0,001), serum glucose (p<0,006), difference in platelets between the first and the third day (p<0,001), hemoglobin (p<0,027) and erythrocytes values (p<0,029). Conclusions IL and listed markers are useful in predicting the severity of AP. According to results of our study, IL-6 and CRP after 48 hours had the best predictive value.
Sa1333 DOES CONCURRENT DIABETIC ACIDOSIS AFFECT CLINICAL COURSE IN PATIENTS WITH HYPERTRIGLYCERIDEMIA PANCREATITIS? Yuchen Wang, Bashar M. Attar, Sara Bedrose, C. Roberto Simons-Linares Backgroud: Hypertriglyceridemia induced acute pancreatitis (HP) is an uncommon condition representing 1-4 percent of overall acute pancreatitis cases. As poor glycemic control in patients with concurrent diabetes represents one of the leading cause, diabetic ketoacidosis (DKA) is frequently associated with HP. The present study aims to characterize HP patients with and without DKA, describe whether and how DKA affects the clinical course of HP. Method: We retrospectively analyzed patients with diagnosis HP (ICD9/10 code for hypertriglyceridemia and ICD 9/10 code for acute pancreatitis) at a large public hospital during 10 years (05/2006 through 05/2015). Diagnosis was confirmed with radiographicproven acute pancreatitis and concurrent serum triglyceride exceeding 1000mg/dl. We collected information regarding basic epidemiologic characters, initial laboratory results, complications from HP and hospital courses. Differences in each variable were compared between DKA group and non-DKA group; BISAP, SOFA, RANSON, APACHE II scores were calculated and compared between groups. . Results: 140 patients with complete profile were included, concurrent DKA was prevalent in 37 (26.4%) cases. Mean (SD) age was 39.6 (9.8) years; 107 (76.4%) were male; mean BMI (SD) was 30.5 (5.7) kg/m2. 65 (46.4%) patients had diabetes mellitus and 60 (42.8%) patients had known history of hyperlipidemia. While significantly more patients with DKA were male (89.2% vs 71.8%, p=0.041) and active illicit drug abuser (18.9% vs 6.8%, p=0.035), there was no statistical difference between groups in age, past medical history, tobacco or alcohol usage and BMI. DKA patient had higher serum glucose and lower serum bicarbonate as anticipated, however no significant difference exist regarding serum lipase, triglyceride, leukocyte count and lactate dehydrogenase. The mean (SD) hospitalization was 7.3 (5) days, with 3.6% (5 cases) mortality. 79 (56.4%) patients received intravenous insulin infusion with mean (SD) length of 4.1 (3.2) days. In DKA group, 62.2% patients had concurrent acute kidney injury during hospitalization, significantly more than non-DKA group (p=0.042). There were no difference in BISAP score and SOFA score between groups, however RANSON score was significantly higher in DKA group (3.97, SD=1.42)than in non-DKA group(2.88 SD=1.78) (p=0.001). Similar results exist for APACHE II score (7.70, SD=4.26 vs 5.39, SD=4.44, p=0.007). Conclusions: Concurrent DKA is prevalent is significant portion of HP cases. Male gender, active illicit drug abuser were more prevalent in DKA group. No significant difference in clinical course exist except for more acute kidney injury with DKA. RANSON score and APACHE II score were significantly higher with DKA, likely representing influences from higher serum glucose and serum bicarbonate, which are accounted in these scoring systems. Clinical course of pateints with and without DKA
Sa1331 CLINICAL IMPLICATION OF REFEEDING SYNDROME BASED ON THE ANALYSIS OF CAUSES OF EARLY MORTALITY IN ACUTE PANCREATITIS Hyun Sun Woo, Jae Hee Cho, Eui Joo Kim, YeonSuk Kim, Suji Kim Background/Aims: Italy's survey reported overall mortality rate of acute pancreatitis (AP) was approximately 5 percent. However early mortality within 3 days of AP has been unexplained. We suspected malnourished patients with AP were related with refeeding syndrome (RFS) causing cardiac failure, elevated liver-function values, etc. It was resulted from fluid and electrolyte shifts during nutritional rehabilitation. Methods: Between 2006 and 2016, 2121 patients were diagnosed with AP in two tertiary medical centers. Among them, 39 (1.8%) patients died in 3 days after admission, and clinical data were retrospectively reviewed. Results: Among 39 AP patients with early mortality, mean age was 60.1 years (range, 27 to 92 years) and there were 30 male patients. The most common cause of AP was alcohol consumption (n=28, 71.8%). Gallstones (n=7, 17.9%), malignancy (n=1, 2.6%) and hypertriglyceridemia (n=1, 2.6%) also induced AP. The causes of early mortality of AP were septic shock (n=15, 38.5%), cardiogenic shock (n=14, 36%), alcoholic ketoacidosis (n=3, 7.7%), arrhythmia (n=5, 12.8%) and respiratory failure (n=2, 5.1%). RFS was suspected in 9 (23%) patients and they were alcoholics with poor nutritional status. After sudden nutritional support, electrolyte imbalance including levels of phosphorus got progressively worse and caused death. We compared variables of 9 patients with RFS and 30 patients without RFS. Patients with RFS had significant lower levels of phosphorus. Conclusions: The 23% of early mortality of AP was related to the refeeding syndrome. Therefore, clinicians should not ignore the possibility of refeeding syndrome in malnourished AP patients with electrolyte imbalance.
S-279
AGA Abstracts
AGA Abstracts
THROMBOSIS OF SPLANCHNIC VEINS DURING A FIRST EPISODE OF ACUTE PANCREATITIS: PREVALENCE AND OUTCOMES Yuchen Wang, Bashar M. Attar, Palashkumar Jaiswal, Diana Plata, Harry Fuentes, Luis Paz Rios, William Trick, C. Roberto Simons-Linares
Background & Aim: Thrombosis of Splanchnic Veins (TSV) is a potentially severe complication of acute pancreatitis. It most commonly affects the splanchnic, portal or superior mesenteric veins. Acute pancreatitis (AP) is the most common gastrointestinal discharge diagnosis in the United States. The aim of this single-center, retrospective cohort study was to investigate the incidence of TSV and to determine the connected risk factors and outcomes. Methods: We performed a retrospective cohort study of consecutive patients admitted with a very first episode of acute pancreatitis at a large public hospital between 01/2013 and 12/ 2014. We identified acute pancreatitis diagnosis by ICD9 code and/or lipase ≥ 3 times the normal upper limit. Two physicians reviewed each case to include only first episodes of acute pancreatitis. We excluded patients who were transferred to our center. We reviewed the abdominal CT scans with contrast from that admission to look for New thrombosis of the Splanchnic Veins. We constructed multivariable logistic regression models using STATA software version 13. Results: We analyzed 460 patients. Mean age was 48 years (range 17 to 89 years), 54% were males. Of 460 acute pancreatitis patients, 108 had an IV contrast enhanced abdominal CT scan. The prevalence of TSV was 6% (7 cases). According to the most common affected vessel we found: Portal vein (4 cases), Splenic vein (2 cases) and SMV (1 case). Only 1 of the 7 cases was anticoagulated; this case was the only death between the 7 cases. The prevalence of pancreatic necrosis was 19%, SIRS on admission was 31%, persistent SIRS at 48h was 19% and AKI was 24%. In Univariate analysis, Alcohol intake, male gender and smoking were found to be risk factors for TSV. In Multivariate analysis the only risk factor for TSV was smoking tobacco (aOR: 1.2, p<0.001; CI 1.1-1.4). We found that AKI was less common among patients without TSV when compared to the TSV group (OR: 0.2; p<0.05; CI 0.2-0.9). After adjusting for admission SIRS, age and gender; TSV was not found to be an independent risk factor for Persistent SIRS, AKI, ARDS, pancreatic necrosis, mortality, ICU, LOS, in-hospital infections, BISAP score, nor recurrent AP. In addition, no significant difference in the recanalization rates was found in those with and without AC (p=NS). Limitations: Retrospective study. Strength: Robust patient cohort. Absence of transferred patients. Conclusion: Thrombosis of Splanchnic Veins incidence was found to be low in our cohort when compared to the reported literature. Moreover, TSV was Not found to impact the outcomes of acute pancreatitis. Smoking should call the physician's attention on the risk of abdominal vein thrombosis in acute pancreatitis. Anticoagulation of abdominal vein thrombosis is still a controversy and no benefit was found in our cohort.
H&E Staining consistent with signet-ring cell carcinoma from pancreas
Left to right : CDX positive, Cytokeratin 20 positive, Cytokeratin 7 negative. This staining pattern would be quite unusual for a pancreatic neoplasm
Sa1330 ARE INTERLEUKINS USEFUL IN PREDICTING THE SEVERITY OF ACUTE PANCREATITIS? Davorin B. C´eranic´, Pavel Skok, Milan Zorman Introduction Severe acute pancreatitis (SAP) develops in 15-25% of patients this disease. Prediction of severity is crucial in clinical practice. Aims To evaluate the role of interleukins and inflammatory markers in a prospective study. Patients and methods Included were 96 patients with AP. Laboratory parameters were analyzed on admission, after 48 hours and during hospitalisation, daily. A binomial logistic regression was performed. Results In the study were 59 (61.5%) males and 37 (38.5%) females, average age 61.5±15.9 years. The etiology was identified as gallstones in 52 %, alcohol in 33 % and other causes in 14 % . Three patients (3%) died due to multi-organ failure. Interleukin-6 (IL-6) has the greatest predictive value in prediction of SAP at admission (AUC=0.78) and after 48 hours (AUC= 0.84). IL-8 (AUC=0.70); IL-10 (AUC=0.74) were also useful markers. In comparison between the values at admission and after 48 hours, CRP has been shown to have better predictive value at follow up (AUC=0.82). At cut-off value of 152, the sensitivity was 81.3% and specificity 68.8%. Useful predictors of SAP were also LDH (p<0,001), serum glucose (p<0,006), difference in platelets between the first and the third day (p<0,001), hemoglobin (p<0,027) and erythrocytes values (p<0,029). Conclusions IL and listed markers are useful in predicting the severity of AP. According to results of our study, IL-6 and CRP after 48 hours had the best predictive value.
Sa1333 DOES CONCURRENT DIABETIC ACIDOSIS AFFECT CLINICAL COURSE IN PATIENTS WITH HYPERTRIGLYCERIDEMIA PANCREATITIS? Yuchen Wang, Bashar M. Attar, Sara Bedrose, C. Roberto Simons-Linares Backgroud: Hypertriglyceridemia induced acute pancreatitis (HP) is an uncommon condition representing 1-4 percent of overall acute pancreatitis cases. As poor glycemic control in patients with concurrent diabetes represents one of the leading cause, diabetic ketoacidosis (DKA) is frequently associated with HP. The present study aims to characterize HP patients with and without DKA, describe whether and how DKA affects the clinical course of HP. Method: We retrospectively analyzed patients with diagnosis HP (ICD9/10 code for hypertriglyceridemia and ICD 9/10 code for acute pancreatitis) at a large public hospital during 10 years (05/2006 through 05/2015). Diagnosis was confirmed with radiographicproven acute pancreatitis and concurrent serum triglyceride exceeding 1000mg/dl. We collected information regarding basic epidemiologic characters, initial laboratory results, complications from HP and hospital courses. Differences in each variable were compared between DKA group and non-DKA group; BISAP, SOFA, RANSON, APACHE II scores were calculated and compared between groups. . Results: 140 patients with complete profile were included, concurrent DKA was prevalent in 37 (26.4%) cases. Mean (SD) age was 39.6 (9.8) years; 107 (76.4%) were male; mean BMI (SD) was 30.5 (5.7) kg/m2. 65 (46.4%) patients had diabetes mellitus and 60 (42.8%) patients had known history of hyperlipidemia. While significantly more patients with DKA were male (89.2% vs 71.8%, p=0.041) and active illicit drug abuser (18.9% vs 6.8%, p=0.035), there was no statistical difference between groups in age, past medical history, tobacco or alcohol usage and BMI. DKA patient had higher serum glucose and lower serum bicarbonate as anticipated, however no significant difference exist regarding serum lipase, triglyceride, leukocyte count and lactate dehydrogenase. The mean (SD) hospitalization was 7.3 (5) days, with 3.6% (5 cases) mortality. 79 (56.4%) patients received intravenous insulin infusion with mean (SD) length of 4.1 (3.2) days. In DKA group, 62.2% patients had concurrent acute kidney injury during hospitalization, significantly more than non-DKA group (p=0.042). There were no difference in BISAP score and SOFA score between groups, however RANSON score was significantly higher in DKA group (3.97, SD=1.42)than in non-DKA group(2.88 SD=1.78) (p=0.001). Similar results exist for APACHE II score (7.70, SD=4.26 vs 5.39, SD=4.44, p=0.007). Conclusions: Concurrent DKA is prevalent is significant portion of HP cases. Male gender, active illicit drug abuser were more prevalent in DKA group. No significant difference in clinical course exist except for more acute kidney injury with DKA. RANSON score and APACHE II score were significantly higher with DKA, likely representing influences from higher serum glucose and serum bicarbonate, which are accounted in these scoring systems. Clinical course of pateints with and without DKA
Sa1331 CLINICAL IMPLICATION OF REFEEDING SYNDROME BASED ON THE ANALYSIS OF CAUSES OF EARLY MORTALITY IN ACUTE PANCREATITIS Hyun Sun Woo, Jae Hee Cho, Eui Joo Kim, YeonSuk Kim, Suji Kim Background/Aims: Italy's survey reported overall mortality rate of acute pancreatitis (AP) was approximately 5 percent. However early mortality within 3 days of AP has been unexplained. We suspected malnourished patients with AP were related with refeeding syndrome (RFS) causing cardiac failure, elevated liver-function values, etc. It was resulted from fluid and electrolyte shifts during nutritional rehabilitation. Methods: Between 2006 and 2016, 2121 patients were diagnosed with AP in two tertiary medical centers. Among them, 39 (1.8%) patients died in 3 days after admission, and clinical data were retrospectively reviewed. Results: Among 39 AP patients with early mortality, mean age was 60.1 years (range, 27 to 92 years) and there were 30 male patients. The most common cause of AP was alcohol consumption (n=28, 71.8%). Gallstones (n=7, 17.9%), malignancy (n=1, 2.6%) and hypertriglyceridemia (n=1, 2.6%) also induced AP. The causes of early mortality of AP were septic shock (n=15, 38.5%), cardiogenic shock (n=14, 36%), alcoholic ketoacidosis (n=3, 7.7%), arrhythmia (n=5, 12.8%) and respiratory failure (n=2, 5.1%). RFS was suspected in 9 (23%) patients and they were alcoholics with poor nutritional status. After sudden nutritional support, electrolyte imbalance including levels of phosphorus got progressively worse and caused death. We compared variables of 9 patients with RFS and 30 patients without RFS. Patients with RFS had significant lower levels of phosphorus. Conclusions: The 23% of early mortality of AP was related to the refeeding syndrome. Therefore, clinicians should not ignore the possibility of refeeding syndrome in malnourished AP patients with electrolyte imbalance.
S-279
AGA Abstracts
AGA Abstracts
THROMBOSIS OF SPLANCHNIC VEINS DURING A FIRST EPISODE OF ACUTE PANCREATITIS: PREVALENCE AND OUTCOMES Yuchen Wang, Bashar M. Attar, Palashkumar Jaiswal, Diana Plata, Harry Fuentes, Luis Paz Rios, William Trick, C. Roberto Simons-Linares