bluuebunny/crossref_metadata_2025 huggingface dataset:
79 A Multi-Center Comparison of Proceduralist Versus Radiology Technician-Driven Fluoroscopy in Endoscopic Retrograde Cholangiopancreatography: Best When You Do It Yourself!
Authors: Hughes Michelle , Khara Harshit S. , Thosani Nirav , Bartell Nicholas , Bittner Krystle , Ullah Asad , Kumar Vikas , Khalid Ammara , Diehl David L. , Confer Bradley , Patil Prithvi , Johnson Alexandra , Kothari Truptesh , Kaul Vivek , Kothari Shivangi
Published: October 2019

INTRODUCTION:

Patients are exposed to radiation during endoscopic retrograde cholangiopancreatography (ERCP) which may increase the cumulative risk of the development of cancer and/or of other radiation-related adverse events. ERCP utilizes radiological guidance to direct diagnosis and therapy of biliary and pancreatic pathology. There is limited data available evaluating if the amount of radiation directed to the patient during ERCP is different by endoscopist-directed fluoroscopy versus when ERCP is assisted by radiology technician. Our aim was to assess the difference in the dose of radiation administered to the patient when fluoroscopy during ERCP is operated by the endoscopist versus the radiology technician.

METHODS:

This is an IRB-approved multi-center retrospective chart review of patients who underwent ERCP between 07/2017 and 11/2018 at three high-volume academic centers. Patient-specific data was collected including demographics, cholecystectomy status and indication for ERCP. Procedural and fluoroscopic data were also obtained. Descriptive and inferential analyses were performed utilizing SPSS software.

RESULTS:

During the study period, a sample of 100 patients that underwent ERCP performed with radiology technician (RT) assistance (two tech-driven institutions; n = 50 each) and a sample of 50 patients with endoscopist-led fluoroscopy (ELF) were compared. Patient characteristics are summarized in Table 1. The most common indication for ERCP was choledocholithiasis (n = 26 vs. 24, RT vs ELF, respectively). Mean procedure time (34.6 vs. 26.6 min, RT vs. ELF; P = 0.056) and mean fluoroscopy time (5.2 vs. 4.9 min, RT vs. ELF; P = 0.897) were similar in both groups. The ELF group obtained a significantly greater number of images during ERCP (RT 9.9 vs. ELF 14.6, P < 0.001). The mean dose of radiation (Gy/cm2) administered to the patient was significantly higher in the RT group (RT 40.6 vs. ELF 20.3; P = 0.016).

CONCLUSION:

Endoscopist-driven fluoroscopy during ERCP is associated with lower radiation dose compared to radiology technician assisted fluoroscopy at high volume ERCP centers. Endoscopists are also better at saving more images during an ERCP. Future education and training of radiation technicians may help reduce the radiation to the patients.
86 Acalculous Cholecystitis: Changing Trends From 2004 to 2014
Authors: Kakked Gaurav , Herman Michael , Persaud Alana , Smith Michael S. , Lung Edward
Published: October 2019

INTRODUCTION:

Acute acalculous cholecystitis (AAC) which accounts for 10% cases of cholecystitis is associated with high morbidity and mortality rates. The management options for AAC range from surgical removal of the gall bladder to emergent drainage either by percutaneous means or endoscopically. Data about the in-hospital outcomes of AAC is sparse.

METHODS:

The NIS is the largest all-payer inpatient database in the United States and contains data from approximately 8 million hospital stays each year. We analyzed the National Inpatient Sample Database (NIS) for all patients in which acute acalculous cholecystitis (ICD-9 codes: 575.0, 575.1) was the principal discharge diagnosis from 2004 to 2014. We further looked at procedure codes Endoscopic retrograde cholangiopancreatography (ERCP), Endoscopic ultrasound (EUS), Percutaneous transhepatic cholangiography (PTC), open and laparoscopic cholecystectomy. The outcome variables were in hospital mortality, length of stay and total hospital charge. Univariate and multivariate analysis was performed adjusted for multiple confounder.

RESULTS:

In 2014 there were 35865 hospital admissions with the principal diagnosis AAC which increased significantly from 23485 in 2004 (P < 0.001). The mean length of stay for acute cholecystitis decreased by 21.6% between 2004 and 2014 (i.e., from 5.1 days to 4.0 days; (P  <  0.05). During the same time period, however, mean hospital charges have increased by 190.5% from US$24 514 per patient in 2004 to US$46847 per patient in 2014 (P  <  0.001). There were no cases of EUS guided drainage in 2004 while in 2014 there were 485 cases. A significantly higher proportion of patients received PTC, ERCP and laparoscopic cholecystectomy in 2014 compared to 2004 (P = 0.001). The in-hospital mortality declined from 1.4% in 2004 to 0.9% in 2014. Factors associated with in-hospital mortality were Diabetes mellitus (OR = 1.76, P = 0.004), presence of Chronic kidney disease (OR = 2.36, P = 0.003), hematologic malignancy (OR = 4.5, P < 0.001) and metastatic cancer (OR = 14.56, P < 0.0001).

CONCLUSION:

The number of cases of acalculous cholecystitis has shown a gradual increase from 2004 to 2014. However there has been a gradual reduction in mortality and length of stay in these patients. While it is associated with increased utilization of ERCP and EUS, causality cannot definitively be established.
90 Factors Associated With Increased Opioid Use in a Retrospective Cohort of 14,140 Acute Pancreatitis Patients
Authors: Twohig Patrick , Sandhu Dalbir S.
Published: October 2019

INTRODUCTION:

Pain management is a critical component of treating acute pancreatitis (AP). No guidelines exist on optimal pain management strategies. Opioids have become a mainstay in the treatment of pain in AP, but there are uncertainties regarding their effectiveness and concerns about their safety. The risk of subsequent opioid dependence (OD) after developing AP has not been well-studied. Our aim is to 1) Investigate the risk of developing OD after having AP, and 2) Evaluate whether patient factors such as age, gender, race, and insurance status affect the risk of developing OD after AP.

METHODS:

We performed a retrospective analysis in the IBM Explorys database (1999–2019), a pooled, de-identified clinical database of over 63 million unique patients across the United States. At the time of analysis there were 63,566,840 patients. Patient populations were identified using SNOMED and ICD codes. Odds ratios were calculated to determine the relationship between AP and OD for the population subgroups outlined above.

RESULTS:

316,450 patients had AP from 1999–2019. 14,140 of these patients also were OD. The odds of being OD after AP was 11.06 (95% CI 10.87, 11.25). Patients under the age of 65 years had the highest risk of developing OD. Patients with Medicaid had the highest risk of any type of medical insurance. Females were more likely to develop OD than males. Caucasian and African American patients had a similar risk of becoming OD. Asian patients were least likely to develop OD. Full results are listed in Table 1. Corresponding Forrest plots of this data are illustrated in Figure 1.

CONCLUSION:

Our results are consistent with what has been observed previously, as an evaluation of opioid use among inpatients with AP also found a significant variation in opioid use among hospitalized patients. High doses of opioids have been shown to result in longer hospitalizations and more adverse outcomes. Prospective trials and systematic reviews have not found that any particular analgesic is superior for pain control in AP patients. There is currently a lack of clinical guidance on the utility and efficacy of using opioids in managing pain from AP. We hope that our results can inform clinicians of different patient factors that may increase the risk of OD after having AP. Future use of drug monitoring systems and electronic health record utilization may help further analyze factors associated with persistent opioid use.
93 Variations of Diagnosis and Management of Immune Checkpoint Inhibitor Pancreatic Injury (ICIPI) and Immune Checkpoint Inhibitor Pancreatitis: A Single Institution Experience
Authors: Shah Ravi , Sleiman Joseph , Simons-Linares Roberto , Faisal Muhammad , Song Jung-Min , Philpott Jessica , Funchain Pauline
Published: October 2019

INTRODUCTION:

Immune checkpoint inhibitors (ICI) have revolutionized the treatment of malignancies, but are limited by immune-related adverse events (iRAE). Pancreatic iRAEs, broadly defined by asymptomatic lipase elevation to complicated pancreatitis, lack clear management. We seek to report rates of varying definitions, evaluations, and management of pancreatic iRAEs, classified as immune-checkpoint inhibitor pancreatic injury (ICIPI) and ICI pancreatitis.

METHODS:

From a database of 1672 patients treated with ICI, data was collected on those with possible pancreatic injury. They were classified into four groups: ICIPI, as defined by either lipase elevation or imaging of pancreatitis due to ICI; ICI pancreatitis, as defined by fulfilling Atlanta criteria; non-ICI asymptomatic lipase elevation; non-ICI pancreatitis. Data on rates of diagnosed pancreatitis, lipase elevations, imaging evidence, symptomatology, treatment, management of ICI, and patient outcome after cessation of ICI were collected.

RESULTS:

Of 31/1672 (2%) patients with pancreatic injury, 7 had ICI pancreatitis, 14 had ICIPI, 6 had non-ICI pancreatitis, and 4 had non-ICI asymptomatic lipase elevations. In the 7 ICI pancreatitis patients meeting Atlanta criteria, 5/7 (71%) had follow up evaluation to rule out other etiologies of pancreatitis. In contrast, only 1/13 (8%) ICIPI patients had a follow up evaluation to meet Atlanta criteria or rule out other etiologies. Of the ICIPI patients, 6/14 (43%) were diagnosed as pancreatitis, 8/14 (57%) were asymptomatic, 9/14 (64%) had lipase >3x upper limit of normal (ULN), and only 1/14 (7%) ICIPI was due to imaging alone (Table 1). Most ICI pancreatitis, 5/7 (71%), and ICIPI, 10/14 (71%) patients received corticosteroids (CS). While 4/7 (57%) ICI pancreatitis patients received intravenous fluids (IVF), only 2/14 (14%) of ICIPI patients did. Of 6/7 (86%) of ICI pancreatitis patients that stopped ICI, 3/6 (50%) reinitiated them. In contrast, 7/14 (50%) of ICIPI patients stopped ICI and 5/7 (71%) reinitiated them (Table 2).

CONCLUSION:

Pancreatic injury is known to be associated with ICI. Efforts to identify and treat those with pancreatic iRAE are critical to avoid delay in ICI therapy. In our study, most patients with ICIPI and ICI pancreatitis received CS. Almost all ICI pancreatitis patients stopped ICI with half reinitiating them, while only half of ICIPI patients stopped ICI with most reinitiating them. Further characterizing outcomes to develop a diagnostic algorithm will enhance care.
94 Necrotizing Pancreatitis Does Not Increase Odds of Mortality: Insights From a National Cohort
Authors: Bhurwal Abhishek , Pioppo Lauren , Tawadros Augustine , Reja Debashis , Andalib Iman , Sarkar Avik , Shahid Haroon , Tyberg Amy , Kahaleh Michel
Published: October 2019

INTRODUCTION:

Although most patients develop mild acute pancreatitis, some progress to necrotizing pancreatitis. Necrotizing pancreatitis has historically been associated with increased mortality as high as 30%. However, there are sparse studies reporting incidence of necrotizing pancreatitis from national cohort and its impact on patient related outcomes. Therefore, we aimed to analyze Necrotizing pancreatitis from a National cohort.

METHODS:

This was a retrospective study utilizing the 2016 National Inpatient Database Cohort for all principal discharges of acute pancreatitis in patients more than 18 years of age utilizing ICD 10 CM codes. Primary outcomes were incidence of necrotizing pancreatitis. Secondary outcomes were mortality, impact on healthcare utilization in terms of length of stay and hospitalization charges. These were then adjusted for confounders utilizing multivariate and Poisson regression analysis. All statistics were performed utilizing STATA software.

RESULTS:

Among total of 288,479 discharges with principal diagnoses of Acute Pancreatitis, 0.84% were necrotizing pancreatitis. Necrotizing pancreatitis significantly more frequent in young adults (49 years vs 51 years, P < 0.0001) and male population (52.69% vs 69.83%, P < 0.0001). As expected, presence of necrosis was associated with increased odds of complications such as Acute kidney injury and Acute respiratory distress syndrome. Approximately, 7% of the necrotizing pancreatitis cohort was associated with pancreatic resection. Acute necrotizing pancreatitis did not significantly increase the odds of mortality as shown in Table 2 after adjustment of confounders. Presence of necrosis was also associated with significantly longer length of stay in the hospital (4.31 days vs 12.10 days, P < 0.0001) and significantly higher total hospitalization costs (9,264$ vs 29,948$, P < 0.0001).

CONCLUSION:

Incidence of Acute necrotizing pancreatitis is approximately 8 per 1000 cases of acute pancreatitis. Even though, necrotizing pancreatitis led to significantly higher longer length of stay and hospitalization charges, mortality was not increased from necrotizing pancreatitis. No significant difference in mortality indirectly indicates aggressive IV fluid therapy, early recognition and resections when indicated. However, further studies are warranted to elucidate the reason explaining necrotizing pancreatitis in young and male population.
95 Prevalence of Intrapapillary Mucinous Neoplasm in Patients With Chronic Kidney Disease
Authors: Kapil Neil , Lamm Vladimir , Mulki Ramzi , Shah Rushikesh , Cai Qiang , Willingham Field , Keilin Steven
Published: October 2019

INTRODUCTION:

The prevalence of intraductal papillary mucinous neoplasm (IPMN) in the general population ranges from 3.3%–9.8%. In patients undergoing liver transplant evaluation, overall prevalence is documented to be 6.6%. So far, the suggested risk factors for IPMN include diabetes, family history of pancreatic adenocarcinoma, and tobacco use. We aim to study the prevalence and risk factors for IPMN formation in patients with chronic kidney disease (CKD).

METHODS:

We performed a retrospective cross-sectional study of patients with CKD who had MRIs of the abdomen performed between the dates of 1/2018 and 12/2018. Independent chart review was conducted and various demographic, clinical, and imaging metrics were extracted. Overall, the prevalence of IPMN was calculated. A student's t-test and chi-square test were used to compare the IPMN group to non-IPMN group.

RESULTS:

A total of 400 patients were reviewed. The total prevalence of IPMN in CKD patients was 13.7% (55/400). In 68% of the study patients, the MRI was done for a kidney transplant evaluation. The average age of patients in the study was 58 ± 14 years, 59% were male and 52% patients were on dialysis. Diabetes and Hypertension accounted for 26% and 45% of CKD respectively. In patients with IPMNs, the average size was 10 ± 5.7 mm; 45% were located in the head, 33% in the body and 22% in the tail. Notably, 16% were main duct IPMNs, 80% were side branch IPMNs and 4% patients had mixed (MD + SB) IPMNs. Amongst the patients with IPMNs, 7.5% of patients had associated high-risk features and were referred for endoscopic ultrasound. Comparison of the IPMN group to non-IPMN group is shown in Table 1. IPMNs were most commonly observed in elderly patients. Gender, dialysis status, etiology of CKD, smoking and alcohol intake did not seem to impact the prevalence of IPMN in CKD patients.

CONCLUSION:

Patients with CKD have a higher prevalence of IPMNs than the general population. We further aim to confirm this interval data with our age and gender matched control group without CKD.
99 Cholangitis in Patients With Pancreatic Adenocarcinoma Does Not Impact Resection Rates in Patients Who Are Undergoing Neoadjuvant Chemotherapy
Authors: Darnell Eli P. , Wang Thomas J. , Lumish Melissa A. , Hernandez-Barco Yasmin G. , Weniger Maximillian , Fernandez-Del Castillo C. , Casey Brenna W. , Krishnan Kumar
Published: October 2019

INTRODUCTION:

Pancreatic adenocarcinoma continues to have a high mortality rate. Successful surgical resection (Whipple procedure) of cancer remains the only potential durable cure. In order to improve survival, many patients receive neoadjuvant chemotherapy prior to surgery, which requires biliary stenting in those patients with jaundice. Some patients will develop cholangitis from transient stent obstruction. The impact of preoperative cholangitis on the ability to get surgery is not clear. We investigate the role of cholangitis in patients with pancreatic adenocarcinoma undergoing neoadjuvant chemotherapy.

METHODS:

We identified all patients of Massachusetts General Hospital (MGH) from 2013 to 2018 who underwent neoadjuvant chemotherapy and received ERCP with metal biliary stenting for jaundice. Chart review was performed to identify patients who had cholangitis. We further determined the rate of successful surgery, time to surgery, and mortality rates. Statistics were performed using the student t-test or Fisher's exact test to establish significance.

RESULTS:

In total, we identified 97 patients who establish care at MGH to pursue neoadjuvant chemotherapy in preparation for curative surgery. Of these 25 had developed at least one episode of cholangitis within one year of diagnosis, 6 had more than one episode, while 72 did not have any episodes of cholangitis. Whipple surgery was attempted in 76% of the cholangitis-1 group compared to 78% of the non-cholangitis group (P = 1.0). The average time to surgery was 194 days in the cholangitis group and 176 days in the non-cholangitis group (P = 0.40). There was no difference in surgical resection rate or time to surgery between patients with more than one episode of cholangitis compared to the non-cholangitis group. There was no difference between groups in six (P = 0.57) or twelve month (P = 0.56) mortality.

CONCLUSION:

Our data reveal that cholangitis within a year of diagnosis does not impact the ability of a patient to undergo successful Whipple operation. We propose that aggressive endoscopic biliary endotherapy should be considered, even in patients with recurrent preoperative cholangitis, to assist with completing neoadjuvant protocols in hopes of a curative surgery.
102 Application of Liquid-Impregnated Surfaces on Gastrointestinal Devices to Reduce Device-Associated Complications
Authors: Zhang Zheng , Seekell Raymond , Jaffe Sarah , Smith J. David , Varanasi Kripa , Hernandez Lyndon
Published: October 2019

INTRODUCTION:

Plastic stents can occlude and require reintervention in up to 75% of cases and this has contributed to more frequent use of much more expensive metal stents. Efforts to increase the duration of plastic stent patency, such as antibacterial stent and hydrophilic coating or design modifications, have met limited success. We hypothesize that a biocompatible liquid-impregnated surface (LIS) coating combining a textured substrate with a liquid lubricant creates a lubricious surface that reduces cell attachment and biofilm formation. Our aim is to determine the ability of LIS coating in an in vitro model to reduce thrombus formation and lumen occlusion.

METHODS:

A polyethylene (PE) tube, made with the same material and size as a 10 Fr biliary stent, is coated with a LIS coating. A Chandler loop assay with freshly harvested bovine blood is used to analyze cell attachment and thrombus formation. Pressure buildup within either PE tubes or 5 Fr polyurethane tubes in presence of whole blood is tested with an occlusion assay. The coated devices are challenged with bile extract solution at 38 °C up to 35 days. The surface composition is analyzed by Attenuated Total Reflection-Fourier Transform Infrared Spectroscopy (ATR-FTIR).

RESULTS:

LIS-coated tubes demonstrated a 100% thrombus reduction using the Chandler loop assay (Figure 1a). The coating remained stable on the surface up to 35 days both in air and in the bile acid solution (Figure 1b,c). LIS-coated tubes were observed to remain patent after 12 hours of swine bile infusion, compared to controls that were completely obstructed. The coated surfaces also reduced occlusion rates in bovine blood (Figure 2).

CONCLUSION:

With a formulation developed through thermodynamic and hydrodynamic validation, a biocompatible LIS coating was applied on a model GI device both internally and externally. In addition to the anti-thrombogenic and antimicrobial performance, the slippery characteristics of the coating can reduce friction, facilitate device deployment during implantation. The coating has the potential to be applied on a GI device such as a biliary stent for a further product development.
103 Pancreatic Adenocarcinoma Following Liver Transplantation: UNOS Data Analysis
Authors: Corral Juan E. , Patel Sheetal , Kröner Paul T. , Wijarnpreecha Karn , Patel Arpan , Al Nimri Sarah M. , Bi Yan , Mousa Omar Y.
Published: October 2019

INTRODUCTION:

Solid organ transplant recipients are at increased risk of de novomalignancies, in some cases up to 15.6%. Data regarding pancreatic cancer following liver transplantation is limited. We aim to evaluate the incidence of pancreatic adenocarcinoma among liver transplant recipients in the United States. Describe survival in those patients and identify subgroup of patients at increased risk.

METHODS:

We examined the United Network of Organ Sharing (UNOS) database and identified patients with pancreatic adenocarcinoma who underwent liver transplant between 1988 and 2016. Patients 18 years of age and older were included. Demographics, primary diagnosis and survival data were recorded. Kaplan-Meier survival analyses and log-rank tests were performed.

RESULTS:

In the UNOS database, survival data regarding 142,488 patients was available and the cause of death was identified in 14,533 liver transplant recipients. A total of 140 patients developed pancreatic adenocarcinoma after liver transplantation. Most common indications for transplantations were Hepatitis C, alcohol cirrhosis and hepatocellular carcinoma (25 [17.9%], 24 [17.1%] and 9 [6.4%] respectively). Annual incidence was 16 pancreatic cancer cases per 100,000 transplant recipients. Compared to national annual incidence of 12.9 cancer cases per 100,000 patients, the relative risk was 1.23 (95% CI 0.59–2.56). Compared to other liver transplant recipients, those who developed pancreatic cancer were older and transplanted earlier in the time period evaluated (P < 0.001 and P = 0.002 respectively). Gender, ethnicity, BMI, and primary diagnosis (i.e., transplant indication) were not significantly different among groups. Patient survival was significantly lower in patients who developed pancreatic adenocarcinoma (Log-rank test P < 0.001) (Figure 1).

CONCLUSION:

Analysis of the UNOS database showed that pancreatic adenocarcinoma is increased among liver transplant recipients without reaching statistical significance. Primary indications for transplantation and demographics were similar among both groups. Our findings suggest that pancreatic adenocarcinoma is more likely associated to long-standing immunosuppression and non-traditional risk factors rather than alcohol consumption or obesity. Further studies describing the natural history of pancreatic cancer after solid organ transplantation are suggested.
106 Trends, Predictors, and Outcomes of Septic Shock in Patients With Pancreatitis
Authors: Albeiruti Ridwaan , Chaudhary Fahad , Hutson William
Published: October 2019

INTRODUCTION:

Patients with pancreatitis are at an increased risk of developing infections. The goal of our study was to determine the association of septic shock on in-hospital outcomes among patients with pancreatitis as well as the risk factors.

METHODS:

A retrospective study using the National Inpatient Sample database (2003–2016) was used to identify acute pancreatitis patients with and without septic shock. A linear regression analysis was used to assess the impact of septic shock on patients hospitalized with acute pancreatitis. A univariate logistic regression was used to determine comorbid conditions and predictors for septic shock in this cohort.

RESULTS:

We identified 7158894 pancreatitis patients between 2003–2016. Patients hospitalized for pancreatitis with and without septic shock had similar baseline characteristics. The incidence of septic shock was highest among patients aged >65 (P < 0.001). Septic shock was associated with significantly higher mortality among those with pancreatitis (34.4% vs 1.5%, P < 0.001). Septic shock was associated with 3 times longer hospitalization (12 days versus 4 days, P < 0.001), higher median hospital cost ($117907 vs $21563, P < 0.001), respiratory failure (60.7% vs 3.6%, P < 0.001), and renal failure (61.6% vs 9.2%, P < 0.001). Septic shock was more likely in patients with comorbidities including diabetes, COPD, and CAD.

CONCLUSION:

Our study found that septic shock in acute pancreatitis patients is associated with increase in mortality, length of stay, and health care utilization. More investigation is needed to further understand how to best mitigate some of these predictors for mortality.
107 The Prevalence of Endoscopic Retrograde Cholangiopancreatography-Related Complications in Patients With Liver Transplant: A Meta-Analysis and Systematic Review
Authors: Al Momani Laith , Alomari Mohammad , Nehme Fredy , Almomani Shaden , Aasen Tyler , Young Mark
Published: October 2019

INTRODUCTION:

Biliary complications following liver transplantation are usually managed with endoscopic retrograde cholangiopancreatography (ERCP); however, the literature on post-ERCP complications remains poorly reported and largely inconsistent in this patient population. Hereby we aimed to systematically review and analyze the literature on complication rates associated with the performance of ERCP in patients with liver transplant.

METHODS:

We performed a comprehensive literature search in PubMed, PubMed Central, Embase, and ScienceDirect databases from inception through May 2019 to identify all the studies that evaluated post-ERCP complications in patients with liver transplant. Effect estimates from the individual studies were extracted and combined using the random effect, generic inverse variance method of DerSimonian and Laird, and a pooled odds ratio (OR) and prevalence were calculated. Forest plots were generated, and publication bias was assessed for using conventional techniques.

RESULTS:

Fourteen studies with a total of 1787 patients were included in this analysis. In total, 3192 ERCPs were performed on these patients. The pooled all-complication rate was 5.2% (95% CI: 0.035–0.075) (Figure 1). Procedural complications analyzed included post-ERCP pancreatitis 3.4% (95% CI: 0.025–0.047), bleeding 1.1% (95% CI: 0.006–0.020), infections 0.2% (95% CI: 0.025–0.047), and cholangitis 0.8% (95% CI 0.004–0.020) (Figure 2a–d). No cases of periprocedural death were reported. The pooled OR for post-ERCP pancreatitis in patients with liver transplant compared to patients without liver transplant was 1.289 (95% CI: 0.455–3.653, P = 0.633, I2 = 72.88%) (Figure 3).

CONCLUSION:

The risk of post-ERCP complications has been a major concern for many endoscopists in patients with liver transplantation. This might be related to theoretical concerns of distorted anatomy and difficult cannulation, combined with a general lack of evidence on the true prevalence of these complications. Our study confirms that post-ERCP complication rates are comparable to the general population undergoing ERCP and hence, peri-procedural evaluation and management should be continued as per the standard of care in this patient population.
112 A Contemporary Analysis of Obese Patient Characteristics and Outcomes With Pancreatitis
Authors: Chaudhary Fahad , Albeiruti Ridwaan , Hutson William
Published: October 2019

INTRODUCTION:

The rates of obesity continue to increase in the US and may have an adverse effect on clinical outcomes in patients with pancreatitis. As the management of acute pancreatitis has improved over the past 2 decades, we sought to evaluate the impact of obesity on patients with pancreatitis using contemporary inpatient data.

METHODS:

The Nationwide Inpatient Sample (2016) was used to identify all adult inpatients older than 18 years with a primary diagnosis of acute and chronic pancreatitis. Primary outcomes included mortality, acute renal failure, acute respiratory failure and septic shock as well as secondary outcomes included length of stay and hospital cost were analyzed.

RESULTS:

During 2016, the national estimate for patients hospitalized with acute and chronic pancreatitis was 519,035. Of these, 70,670 (13.6%) patients carried a diagnosis of obesity. Patients hospitalized for pancreatitis with and without obesity had similar baseline characteristics. Patients with obesity were more likely to be younger (35% vs 31%, P < 0.001), female (35% vs 31%, P < 0.001), and Hispanic (15% vs 11%, P < 0.001). These patients presented to smaller hospitals (70% vs 48%, P < 0.001). Additionally, the etiology of pancreatitis was less likely to be a biliary source (67% vs 79%, P < 0.001). Obese patients had a lower likelihood of mortality (1.5% vs 2.1%, P < 0.001) and septic shock (2.7% vs 2.9%, P < 0.001) but were more likely to have respiratory failure (7.9% vs 7.2%, P < 0.001). Both populations had a similar median length of stay (4) however obese patients had a higher cost of hospitalization ($34,180 vs $29186).

CONCLUSION:

Patient with obesity seem to have a lower likelihood of mortality and biliary causes of pancreatitis. Further, larger epidemiologic studies are needed for further elucidate the exact cause of this finding.
113 Are Antibiotics Necessary for EUS-FNA of Pancreatic Cysts: A Retrospective Study
Authors: Badrinath Madhuri , Kanagalingam Gowthami , Iorio Natalya , Sapkota Bishnu
Published: October 2019

INTRODUCTION:

Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is commonly used to further characterize cystic lesions of the pancreas. Antibiotic prophylaxis has been recommended by the Americal Society for Gastrointestinal Endoscopy for EUS-FNA of cystic pancreatic lesions. The aim of this study was to compare the rate of post-procedural infection in patients who received periprocedural antibiotics for EUS-FNA of pancreatic cystic lesions versus those who did not.

METHODS:

A retrospective review of medical records of individuals with pancreatic cysts who underwent EUS-FNAs at a tertiary academic hospital between January 2015 and March 2018 was performed. All procedures were performed by four board-certified gastroenterologists. The data reviewed included patient demographics, cyst description, FNA needle size, cytology and use of antibiotics. Post-procedural infections were identified by the presence of leukocytosis, fever, or positive blood cultures during follow-up clinic or hospital visits for 30 days after FNA. Excluded from the study were solid neoplasms, obvious side branch intraductal papillary mucinous neoplasm without high risk features and subjects with evidence of infection or leukocytosis before the FNA.

RESULTS:

Two hundred and ten EUS-FNA procedures were included in this analysis. Ninety six were males and 114 were females; median age was 65 years. Cysts were 1–5 cm in diameter and evenly distributed throughout the pancreas. One hundred and fifteen of the 210 (55%) cysts were >2 cm and 95 (44%) were <2 cm. 27 out of 210 (13%) were pancreatitis related cysts. 22-gauge needle was used for 55% of the procedures with the remaining procedures using 19 and 25-gauge needles. Eighty nine of 210 (43%) patients received periprocedural antibiotics. Only one of the total 210 patients (0.4%) developed post-procedural gram-negative bacteremia related to EUS within 1 week of procedure. This patient had received periprocedural antibiotics. None of the patients in the “no antibiotic” group had post-procedural infections (Table 1).

CONCLUSION:

The evidence supporting universal use of antibiotics for all cystic lesions as recommended is lacking and overall infection risk with FNA is low, at approximately 0.3% based on small studies. Our study of 210 patients including pancreatitis related cysts demonstrate that routine use of antibiotics may not be required for FNA of pancreatic cysts. Further prospective studies may be required to support this.
114 Opportunistic Screening of Bone Mineral Density With CT Scans in Chronic Pancreatitis
Authors: Manickavasagan Hanisha , Shah Zarine , Hart Phil , Lara Luis , Hinton Alice , Lu Andrew , Yadav Dhiraj , Conwell Darwin
Published: October 2019

INTRODUCTION:

Osteoporosis and fragility fractures have been repeatedly shown to increase morbidity, mortality and socioeconomic costs. Chronic pancreatitis (CP) has multiple shared risk factors and complications that promote an imbalance in bone mineralization and remodeling which ultimately contributes to a high prevalence of metabolic bone disease. However, in the absence of societal guidelines regarding screening, dual-energy x-ray absorptiometry (DEXA) scans are not routinely performed and are not universally covered by insurance. While DEXA scan is the gold standard to assess bone mineral density, a Computed Tomography (CT) L1 vertebral density less than 135 Hounsfield Units (HU) has been validated to diagnose osteoporosis in the general population. The aim of this proof of concept study was to determine if the CT L1 vertebral threshold of 135 HU is also valid as an opportunistic screening cut-point for osteoporosis in chronic pancreatitis patients.

METHODS:

We selected patients with a definitive diagnosis of CP (according to the American Pancreatic Association guidelines) who were enrolled into The Ohio State Wexner Medical Center Pancreas Disease Biobank. Basic demographic information was abstracted including age, sex, race, BMI, smoking and alcohol history. Pertinent laboratory values and imaging studies, including DEXA scans, were also obtained from these patients. Baseline L1 vertebral HU values on CT scans were determined for BMD assessment (Pickhardt et al, Annals of Internal Medicine 2013).

RESULTS:

Sixty-four patients with definite CP were identified, including 27 (42%) with a CT and DEXA scan. Of these, 15/27 (56%) had evidence of metabolic bone disease (z-score < −1.5), including 15% with osteoporosis. Mean L1 HU value in those with osteoporosis was 106. There was a statistically significant association between osteoporosis (z score < −2.5) and the CT L1 HU threshold of 135 (P = 0.025, positive likelihood ratio of 8.62, PPV 60%). The L1 HU threshold of 135 had sensitivity of 75% and specificity of 91.3% for osteoporosis and a NPV of 95.45%.

CONCLUSION:

CT scans performed during routine clinical care of patients with CP may be useful for opportunistic screening for osteoporosis using L1 HU attenuation, especially at a threshold of 135. Larger sample sizes of patients are needed to further develop risk stratification models in CP considering other clinical risk factors.
116 The Impact of Laparoscopic Cholecystectomy on 30-Day Readmission Rate for Acute Cholangitis Patients: A Single Center Study
Authors: Alsayid Muhammad , Awadalla Mohanad , Albo Betty , Talat Arslan , Wassef Wahid
Published: October 2019

INTRODUCTION:

Acute cholangitis is a serious inflammatory and infectious disease of the bile duct that requires prompt treatment. Choledocholithiasis is the main cause of acute cholangitis and requires biliary clearance using endoscopic retrograde cholangiopancreatography (ERCP). Following endoscopic clearance of the bile duct in patients with acute cholangitis, laparoscopic cholecystectomy (LC) is recommended for patients with gallstones. However, the timing of LC following acute cholangitis is still debatable. The aim of our study was to assess the impact of performing LC during admission following ERCP on the 30-day readmission rate.

METHODS:

A retrospective cohort study of acute cholangitis patients between April 2013 and May 2018. Patients were 18 years or older with a definite diagnosis of acute cholangitis based on Tokyo guidelines 2018. We only included acute cholangitis patients who underwent ERCP with complete clearance of the bile duct. Patients with malignant biliary strictures, a history of cholecystectomy, acute cholecystitis, intrahepatic ductal stones, primary sclerosing cholangitis, or cirrhosis were excluded. The primary outcome of the study was the 30-day readmission rate.

RESULTS:

A total of 95 patients with acute cholangitis were included in the study (Tables 1 and 2). Of these patients, 35 patients (36.8%) underwent LC during admission. The 30-day readmission rate was significantly lower in the LC group compared to the ERCP alone group (2.8% vs. 26.6%, P 0.003). There were no reported deaths in the LC group within 30 and 90 days of discharge, however the mortality rates in the ERCP alone group were 5.0% and 6.6%, respectively. In a multivariate analysis, performing LC during admission was an independent factor for 30-day readmission after adjusting for all other factors, where patients who underwent LC during admission had 90% less chance of readmission within 30 days (OR 0.1, 95% CI (0.01–0.86), P 0.03) (Table 2).

CONCLUSION:

Performing laparoscopic cholecystectomy during admission for acute cholangitis patients following endoscopic clearance of the bile duct was associated with a significant decrease (Absolute Reduction Rate 23.8%) in 30-day readmission rate. Several studies reported the safety of early LC in acute cholangitis patients as well as a decrease in the recurrence of biliary symptoms. Therefore, performing LC during admission should be recommended for acute cholangitis patients following endoscopic clearance of the bile duct.
130 Focusing With a New Lens: Analyzing the Quality of Internet Literature Related to the Gut Microbiome
Authors: Clarke Lindsay , Baumgartner Scott , Szvarca Daniel , Tabbara Nadeem , Basso Jessica , Dawit Lillian , Dave Jenny , Borum Marie
Published: October 2019

INTRODUCTION:

The study of intestinal microbiota and its potential impact on human disease is an emerging field of research. Investigations initially focused on gastrointestinal disorders, but have expanded to include issues related to metabolic, immune, and neurologic function. Since individuals increasingly use electronic resources for medical decisions, assessment of available information is important. This study evaluated the readability, quality and use of evidence-based support of readily accessible online information about intestinal microbiota.

METHODS:

The search terms “gut microbiome” were inputted into Google. Exclusion criteria included websites that were non-accessible, included videos without transcripts, provided veterinary information or were duplicates. Sites were categorized by intended audience, either patient or professional. Readability was determined using the validated Flesch-Kincaid Grade Level Calculation. Websites were reviewed for inclusion of references, provision of additional links for further reading, and the acknowledgement of areas of uncertainty. Statistical analysis using a two-tailed Fisher's Exact Test and a Two-Sample T-test were used with a P-value set at < 0.05.

RESULTS:

100 websites were assessed with 87 meeting criteria for inclusion. 46 (52.9%) were intended for patients and 41 (47.1%) were for medical professionals. The average Flesch-Kincaid Grade level was 14.1, with significant difference (P < 0.0001) between patient (12.6 grade level) and professional (15.8 grade level) websites. 58.6% (25 patient; 26 professional) of websites provided additional links for further information. While 36.7% (12 patient, 20 professional) of all websites acknowledged areas of uncertainty, patient websites significantly more often (P = 0.04) acknowledged areas of uncertainty compared to professional. Patient sources were significantly (P < 0.0001) less likely to provide references (34.7%) as compared to non-patient sources (87.8%).

CONCLUSION:

Online resources on gut microbiome are readily accessible for patient and professional audiences. However, the readability of patient information exceeded the NIH 6th grade recommended reading level. Additionally resources infrequently provided references, links for additional information or acknowledged areas of uncertainty. As the gut microbiome becomes increasingly studied, it is critical that online information be readable and supported by evidence based research.
131 What's Your Gut Feeling? Evaluating Patient Resources on the Impact of the Gut Microbiome on Disease
Authors: Szvarca Daniel , Baumgartner Scott , Clarke Lindsay , Tabbara Nadeem , Basso Jessica , Borum Marie
Published: October 2019

INTRODUCTION:

The gut microbiome is implicated in the pathogenesis of several inflammatory disorders and reported to influence extra-intestinal diseases, including malignancy, neuropsychiatric and cardiovascular disease (CVD). As dysbiosis is implicated in multiple health concerns, the accessibility and accuracy of information available to patients needs review. This study evaluated online sources addressing the role of the gut microbiome in-and-beyond gastrointestinal disease.

METHODS:

“Gut microbiome” was entered into Google to obtain the first 100 websites. Websites were excluded if non-accessible, duplicates, videos without transcripts or discussed veterinary topics. Sites were categorized by intended audiences: patient or professional. Sites were assessed for discussion of diseases, references and acknowledgement of uncertainty of claims. Readability was determined using the validated Flesch-Kincaid Grade Level Calculation. Statistical analysis used a two-tailed Fisher's Exact Test with P-value set at < 0.05.

RESULTS:

87 websites met inclusion criteria: 46 (53%) intended for patients, 41 (47%) intended for professionals. The average readability grade level for patient sites was 12.6 compared to professional sites at 15.8 (P < 0.0001). 69 sites discussed dysbiosis and disease: 38 GI (C. difficile, IBD, IBS) vs. 66 extra-intestinal disorders (psychiatric, neurologic, obesity, CVD, malignancy, other inflammatory conditions). 52 (60%) sites (16 patient; 36 professional) provided references; fewer in patient vs. professional sites (P < 0.0001). Patient sites less frequently provided references compared to professional sites when discussing psychiatric disease (P = 0.017), neurologic disease (P = 0.001), obesity (P < 0.001), CVD (P = 0.016), C. difficile (P = 0.035), IBD (P = 0.023) and cancer (0.022). Of those sites that discussed gut microbiome in relation to disease, 44 (64%) provided references and 29 (42%) noted uncertainty in claims with no significant difference between patient and professional sites.

CONCLUSION:

The functional gut microbiome may have a significant role in many gastrointestinal and extra-intestinal disorders. The content of patient intended sources about dysbiosis infrequently provides references, inadequately addresses areas of uncertainty and had a higher than NIH recommended 6th grade reading level. This study suggests a need for more evidence-based information with greater patient-centered language among online resources available to patients.
134 Fecal Microbiota Transplantation for Recurrent Clostridioides difficile Infection: Efficacy and Predictors of Success
Authors: Abdallah Mohamed , Abdalla Abdelmohaymin , Wiedel Noah , Baloun Brett , Gilbert Jorge
Published: October 2019

INTRODUCTION:

Clostridioides (formerly Clostridium) difficile infection (CDI) is the most commonly identified cause of healthcare-acquired infections in the united states (US). Fecal microbiota transplantation (FMT) is recommended for patients with three or more episodes of CDI. We aim to examine factors associated with the success of FMT in our institution.

METHODS:

A retrospective study of 59 patients who underwent FMT for CDI at Sanford Medical Center, Sioux Falls SD, the US between 2013–2018. All patients underwent FMT via colonoscopy. Antibiotics prior to FMT, donor screening, preparation and delivery of FMT, and post-procedural follow up were based on a standardized protocol in our institution. Data on baseline characteristics, CDI, safety and success rate of FMT (defined by resolution of symptoms and absence of CDI recurrence at 8 and 52 weeks) were collected.

RESULTS:

Baseline characteristics of our study population are shown in (Table 1). The mean age at FMT was 57 years (19–92 years). There were 96% Caucasians and 76% of females. 40% and 35% had three and four episodes of CDI prior to FMT, respectively. Antibiotics were implicated in CDI development in 80% of subjects, most commonly: penicillins (28.8%), cephalosporins (28.8%) and fluoroquinolones (23.7%). 20% had inflammatory bowel disease (IBD), 47% were on proton pump inhibitors (PPIs), and 22% were on immunosuppressants at the time of FMT. Regarding antibiotics used to treat CDI: 58/59 patients received at least one trial of oral vancomycin (84% had vancomycin with six weeks taper), 72% had oral metronidazole and 15% had fidaxomicin. In patients with available data, the success rate of FMT at 8 and 52 weeks was 82.7% (48/58) and 82.6% (43/52), respectively. Two patients (3.4%) had a repeat FMT for CDI recurrence. No major complications, mortalities related to FMT were reported in our study. Failure of FMT at 8 and 52 weeks was associated with female gender, IBD, and immunosuppressants. In our study, IBD was associated with hypertension, PPI, immunosuppressants, and FMT performed without antibiotic coverage for CDI.

CONCLUSION:

FMT is safe and effective for recurrent CDI. In our study, we demonstrated that IBD and immunosuppressants, closely related variables, were associated with FMT failure. Previous studies have shown that IBD is associated with poor outcomes in CDI, and in FMT for CDI. However, it is not clear why FMT failures occurred more frequently in females. Prospective studies with larger sample size are needed.