bluuebunny/crossref_metadata_2025 huggingface dataset:
29 Cannabis Use Is Associated With Worse Outcomes in Acute Pancreatitis: Analysis of a Large Database
Authors: Salazar Miguel , Saleh Mohannad Abou , Barkin Jodie A. , Elkhouly Mohamed A. , Mansoor Emad , Barkin Jamie S. , Simons-Linares Roberto
Published: October 2019

INTRODUCTION:

Cannabis continues to be legalized in the United States and there is also increasing inconclusive evidence about the impact of cannabis in acute pancreatitis (AP). The aim of this study was to investigate the impact of cannabis use among all patients with AP.

METHODS:

We queried a commercial database (Explorys Inc, Cleveland, OH, USA), an aggregate of electronic health record data from 26 major integrated US healthcare systems. We identified a cohort of patients with a Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) diagnosis of AP. We then identified cannabis-user (CU) patients and compared them with non-CU. Logistic regression models were constructed.

RESULTS:

Of the 62,817,650 individuals in the database, we identified 308,350 (0.49%) individuals with AP. Out of those, 14,740 (0.05%) individuals were CU. Interestingly, CU were more likely to be male [OR 1.79; 95% CI: 1.73–1.85, P < 0.0001], African American [OR 2.55; 95% CI: 2.46–2.64, P < 0.0001], younger (<65 years old) [OR 9.49; 95% CI 8.86–10.16, P < 0.0001], tobacco smokers [OR 2.08; 95% CI: 1.98–2.19, P < 0.0001], alcohol consumers [OR 2.00; 95% CI: 1.94–2.07, P < 0.0001] and obese [OR 1.13; 95% CI: 1.08–1.19, P < 0.0001] (Table 1, Figure 1). CU were more likely to have SIRS [OR 1.43; 95% CI: 1.37–1.49, P < 0.0001], AKI [OR 1.45; 95% CI: 1.40–1.50, P < 0.0001], acute respiratory failure [OR 1.45; 95% CI: 1.38–1.51, P < 0.0001], ileus [OR 1.28; 95% CI: 1.20–1.37, P < 0.0001], shock [OR 1.23; 95% CI: 1.16–1.32, P < 0.0001], sepsis [OR 1.31; 95% CI: 1.23–1.39, P < 0.0001], altered mental status [OR 2.00; 95% CI: 1.90–2.10, P < 0.0001], enteral tube feeding requirement [OR 1.46; 95% CI: 1.34–1.60, P < 0.0001], portal vein thrombosis (PVT) [OR 1.35; 95% CI: 1.17–1.56, P < 0.0001], pulmonary embolism (PE) [OR 1.21; 95% CI: 1.12–1.31, P < 0.0001], to receive opiates [OR 1.87; 95% CI: 1.79–1.96, P < 0.0001], to undergo abdominal CT scan [OR 1.59; 95% CI: 1.54–1.64, P < 0.0001], and less likely to have cholangitis [OR 0.35; 95% CI: 0.31–0.41, P < 0.0001], to undergo MRCP [OR 0.65; 95% CI: 0.57–0.75, P < 0.0001], ERCP [OR 0.51; 95% CI: 0.48–0.55, P < 0.0001] (Table 2).

CONCLUSION:

Cannabis users have worse outcomes in AP and this could be potentially explained by tobacco smoking, obesity and alcohol consumption rates that were higher in CU. Further studies to corroborate our findings are needed, especially looking at the route, frequency, modality and amount of cannabis intake in patients with AP.
36 Integrated Molecular Pathology as a Predictor of Malignant Transformation of Pancreatic Cysts: A 6-Year Follow-Up
Authors: Ku Lawrence , Yoo Timothy , Sikavi Cameron S. , Kung Jonathan , Hou Linda A. , Reicher Sofiya , Eysselein Viktor E.
Published: October 2019

INTRODUCTION:

2018 ACG guidelines recommend surgical evaluation for pancreatic cysts with high-risk features. Integrated Molecular Pathology (IMP) combines molecular and biochemical analysis with cytology to improve prediction of malignant transformation. We aim to characterize the long-term performance of IMP.

METHODS:

All pancreatic cystic lesions from prospectively acquired patients with EUS-FNA and IMP (PancraGEN, Interpace Diagnostics) from 9/2010 to 9/2013 were retrospectively analyzed. Known pancreatic adenocarcinoma, serous cystadenoma, or pseudocyst were excluded. Data on patient demographics; EUS and cross-sectional imaging; cyst fluid biochemical and molecular analysis; and cytology were collected. Cystic lesions with low malignant potential were classified as “benign” or “statistically indolent” by IMP and “statistically higher risk” or “aggressive” for those with high malignant potential. Final diagnosis was based on surgical pathology when available, repeat biopsy or imaging, and on length of clinical follow up.

RESULTS:

69 patients with mean age 69.9; 36.2% male were included. Median follow-up was 68.5 months (0.4–99.6); 3 patients were lost to follow-up. Average cyst size was 2.3 cm (0.2–15.3). 22/69 (31.9%) cysts were in the head, 13/69 (18.8%) in the neck, 23/69 (33.3%) in the body, and 11/69 (15.9%) in the tail of the pancreas. 10 patients underwent resection or enucleation. IMP classified 38/69 (55.1%) as benign, 27/69 (39.1%) as statistically indolent, 1/69 (1.4%) as statistically higher risk, 2/69 (2.9%) as aggressive, and 1/69 (1.4%) as indeterminate. Final diagnosis was pancreatic adenocarcinoma in 5/69 (7.2%), mucinous cystadenoma in 10/69 (14.5%), branch type IPMN in 37/69 (53.6%), serous cystadenoma in 13/69 (18.8%), and indeterminate in 4/69 (5.8%). Final diagnosis of adenocarcinoma was in 2/38 (5.3%) classified as benign by IMP, 2/27 (7.4%) statistically indolent lesions, 0/1 (0%) statistically higher risk lesions, 1/2 (50%) aggressive lesions, and 0/1 (0%) indeterminate lesions. A composite of high malignant potential on IMP or high-risk features based on ACG guidelines yielded a sensitivity of 100%, specificity of 81.3%, PPV of 29.4%, and NPV of 100% (Table 1).

CONCLUSION:

Combining high-risk features based on ACG guidelines with IMP is a valuable predictor of malignant transformation of pancreatic cysts, with high sensitivity and NPV based on median 6-year follow-up, which to our knowledge is the longest reported thus far.
39 Impact of Cannabis Use on Chronic Pancreatitis: A 10-Year Analysis of the National Inpatient Sample Database
Authors: Mbachi Chimezie , Kroner Paul T. , Barkin Jodie A. , Wang Yuchen , Demetria Melchor V. , Barkin Jamie S. , Simons-Linares Roberto
Published: October 2019

INTRODUCTION:

Chronic pancreatitis (CP) is a debilitating chronic disease and significantly impacts patient's quality of life. There is evidence that cannabinoids reduce markers of inflammation and fibrosis in pancreatic stellate cells; Cannabis is becoming increasingly popular and there are currently 33 states in the US that have approved medical cannabis while 10 states have approved cannabis for recreational use. We investigated the national trends in prevalence, mortality, length of stay (LOS), hospitalization charges and cost of chronic pancreatitis patients and compared between cannabis-exposed (CE) and non-cannabis-exposed (non-CE).

METHODS:

The National Inpatient Sample (NIS) database from 2005 to 2014 was queried for all patients with a primary discharge diagnosis of CP as per the International Classification of Diseases 9th revision (ICD-9) code 5771. Active exposure to cannabis was ascertained based on ICD-9 code 304.3X and 305.2X. We compared CE vs. non-CE patients. Outcomes included in-hospital mortality, length of stay (LOS), inflation adjusted charges and cost. Propensity match analysis for age, gender, race, median income quartile, hospital characteristics and Elixhauser comorbidity index and multivariable logistic regression models were performed using STATA 14 software.

RESULTS:

Over 31,481 patients with CP as the primary diagnosis were analyzed. Cannabis-exposure prevalence was 1.4% (447 patients). The mean age of CP patients was 49. Patients exposed to cannabis were younger (42 vs 49-year-old, P < 0.001) and mostly males (69% vs 49.7%, P < 0.001). After adjusting for these factors, CE patients had lower total charges compared to non-CE (US$ 21,589 vs. 30,291 P < 0.001) (Figure 1a). CE patients were also hospitalized for fewer number of days when compared to non-CE patients (3.84 vs 5.19 days). There was a significant downward trend in the prevalence of chronic pancreatitis admissions (P < 0.001) amongst non-CE patients while there was an upward trend in the prevalence of chronic pancreatitis admissions amongst CE patients (Figure 2a, b). Interestingly, after matching for age, gender and comorbidities – CE patients had lower inpatient mortality (P = 0.059).

CONCLUSION:

In patients admitted with a primary diagnosis of CP, CE patients had fewer length of stay, hospitalization cost and inpatient mortality. The interplay of these factors remains unknown and studies looking at cannabis strength/dose, route and consumption frequency are needed.
40 Predictors of Acute Respiratory Distress Syndrome in Patients Hospitalized With Acute Pancreatitis
Authors: Gajendran Mahesh , Loganathan Priyadarshini , Collins Laura , Prakash Bharat , Umapathy Chandraprakash , Gupta Vineet
Published: October 2019

INTRODUCTION:

Acute Pancreatitis (AP) has been associated with organ failures and systemic complications, with acute respiratory failure (ARF) being the most common followed by acute kidney injury (AKI). Population-based data on the effect of ARF in AP is limited. Previous studies are derived from single-tertiary care referral centers, which do not represent the community setting of all patients with AP, but rather a “sicker” group of patients. The aims of this study are: (1) to measure the prevalence of ARF in AP, (2) to analyze the trends of ARF in AP patients, (3) to investigate the clinical predictors for ARF in patients with AP, and (4) to measure the outcome comparisons such as length of stay in hospital, hospital cost, and mortality for patients with and without ARF.

METHODS:

This is a retrospective cohort study using the Nationwide Inpatient Sample (NIS) database from the year 2005 to 2014. The study population consisted of all hospitalizations with a primary or secondary discharge diagnosis of AP using the ICD-9-CM code 577.0. Patients with ARF were identified through querying the ICD-9 CM codes 518.5, 518.81, or 518.82.

RESULTS:

During the 10-year period from 2005 to 2014, there were approximately 4.2 million hospitalizations with a discharge diagnosis of AP, out of which 5.1% were associated with ARF. The mortality rate in patients with AP-ARF is 26.1% when compared with the overall mortality rate of 2% in AP patients. A significant proportion of patients with AP-ARF also had co-existing organ failures, mainly acute renal failure (56% vs. 10.1%), hematological dysfunction (19.3% vs. 5.2%), cardiogenic shock (12% vs. 2.5%) and hepatic failure (13.8% vs. 2.3%). Patients with severe sepsis/septic shock are the strongest predictor for developing ARF with an odds ratio (OR) of 9.5, followed by acute renal failure (OR 4.2), hepatic dysfunction (OR 2.4) and cardiogenic shock (OR 2.3). The occurrence of ARF was also associated with increased length of stay (19.9 days vs 6.4 days), increased need for mechanical ventilation (65.5% vs 0.8%), and increased hospital charges ($237,082 vs $55,961) compared to AP patients without ARF.

CONCLUSION:

In this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalization charges in patients with AP. This underlines significantly higher resource utilization in patients with a dual diagnosis of AP-ARF.
41 Outcomes and Safety of ERCP in Nonagenarians Compared to a Younger Cohort
Authors: Walker John T. , Shah Ruchit , Patel Sunny , Khara Harshit S. , Diehl David L. , Confer Bradley
Published: October 2019

INTRODUCTION:

Limited data exists regarding safety of ERCP in elderly patients, particularly nonagenarians. Anecdotal experience suggests technical difficulty of ERCP in elderly patients may be increased by anatomic abnormalities such as large hiatal hernia and peri-ampullary diverticula. Several small studies suggest increased ERCP-related adverse effects in the elderly. We aim to evaluate the safety and difficulty of ERCP in nonagenarians compared to a younger cohort of patients.

METHODS:

A prospectively maintained endoscopy database was queried for patients age ≥90 years and patients age 40–69 years undergoing ERCP from 2013 to 2018. One hundred eleven nonagenarian patients who underwent 165 procedures were identified. One hundred eleven patients from a potential 1,982 patients in the younger cohort were randomly selected. Of the 111 patients included in the younger cohort, 205 ERCPs were performed. Outcomes were compared using student's t-tests for continuous variables and Fisher's Exact tests for categorical variables. A general estimating equation was utilized to calculate odds ratio comparing the groups by outcome.

RESULTS:

The mean age in the nonagenarian cohort was 92.4 (±2.2) years compared to 51.4 (±14.3) years for the young patients. In the elderly group, 37 (33%) were male compared to 40% (N = 44) for the young patients. The most common indication for ERCP was choledocholithiasis (38% nonagenarian vs. 24% young). There was no difference in difficulty passing the duodenoscope between the older group (7.3%) and young group (7.7%), OR 0.93 [0.35, 2.48], P = 0.88. There was a higher rate of peri-ampullary diverticula in nonagenarians (16.4%) compared to young patients (3.4%), OR 5.53 [1.45, 21.15], P = 0.01. There was no statistical difference in failed cannulation for the elderly group (5.5%) vs. the young group (2.9%), OR 1.91 [0.61, 6.00], P = 0.27) or need for pre-cut access in the elderly cohort (10.9%) vs. the young group (8.3%), OR 1.67 [0.37, 7.53], P = 0.50. Most importantly, there was no difference in adverse events between nonagenarians (9.1%) and younger patients (9.3%), OR 0.98 [0.49, 1.94], P = 0.60).

CONCLUSION:

Despite perceived increased risk and difficulty performing ERCP in nonagenarians, our data demonstrate success rate and number of adverse events of ERCP is similar to younger patients. Based on this data, reasonable informed consent can be given regarding the safety and technical success of ERCP in nonagenarians.
42 Safety of Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Patients With Age ≥80: A Nationwide Analysis
Authors: Radadiya Dhruvil K. , Devani Kalpit H. , Charilaou Paris , Patel Pranav D. , Young Mark , Reddy Chakradhar
Published: October 2019

INTRODUCTION:

Endoscopic retrograde cholangiopancreatography (ERCP) is a necessary procedure for exploration and management of pancreaticobiliary ductal system disorders. Safety of ERCP in the elderly population with more underlying co-morbidities remains a concern. We aimed to study if ERCP, particularly for biliary calculus (BC)-related indications, is associated with higher complications including mortality in patients with age ≥80.

METHODS:

We performed a retrospective analysis using data from the National Inpatient Sample (NIS) from the year 2016. We included all adult patients admitted with BC who underwent ERCP, and we further identified those with concurrent pancreatitis and/or cholangitis, using ICD-10-CM codes. Patients with missing information on age, gender or inpatient mortality were excluded. We analyzed patients by two groups: age <80 and ≥80 years. Chi-square analysis and t-tests were used to compare categorical and continuous variables, respectively. Predictors of ERCP-related complications, including inpatient mortality, were assessed by multivariable logistic regression analysis.

RESULTS:

Total of 102,095 patients were included in the study who underwent ERCP for BC related etiology, out of which 20,530 (20.1%) were patients age ≥80 years. In the age ≥80 group, mean age was 85.4 years, and 56.5% patients were female. Unadjusted mean length of stay (6.3 vs. 5.3 days), hospitalization costs ($75,326 vs. $72,110) and inpatient mortality (2.2% vs. 0.8%) were significantly higher in patients with age ≥80. BC without pancreatitis or cholangitis was the most common indication for ERCP in both groups. Prevalence of complications related to ERCP were comparable between two groups except for cardiorespiratory complications and mortality (Table 1). On multivariate analysis, patients with age ≥80 had statistically no significant difference in complications in compared to patients with age <80 years (aOR: 0.96, 95% CI 0.92–1.01, P = 0.133). Among all patients, ERCP performed for biliary pancreatitis (BP) had 70% lower rate of complications while ERCP for cholangitis had 26% higher rate compared to ERCP for simple BC (Table 2).

CONCLUSION:

In the United States, about 1 in 5 ERCP for BC are performed in patients with age ≥80. Overall, BP is associated with significantly lower risk of complications. Among patients undergoing ERCP for BC-related indications, patients with age ≥80 do not carry a higher risk of ERCP-associated complications.
43 Non-Alcoholic Fatty Liver Disease (NAFLD) Is Associated With Severe Acute Pancreatitis (SAP)
Authors: El Kurdi Bara , El Iskandarani Mahmoud , Babar Sumbal , Haddad Ibrahim , Alomari Mohammad , Young Mark
Published: October 2019

INTRODUCTION:

Approximately 15 to 25 percent of patients with AP go on to develop severe AP (SAP) with mortality rising up to 20% as this transition happens. This underlies the significance of identifying predictors of deterioration to SAP. The pancreas is often spared from hepatic disorders, however in non-alcoholic fatty liver disease (NFALD), the pancreas can also be involved mainly through pancreatic peripancreatic fat deposition. We hypothesized that increased fat deposition in and around the pancreas would lead to increased severity of AP. Therefore, we have performed a comprehensive systematic review and meta-analysis to we evaluate NAFLD's association to SAP.

METHODS:

A systematic review was conducted in Pubmed, EMBASE, and Cochrane databases from inception through April 2018 to identify studies which explored the correlation between NAFLD and SAP was conducted. Conference abstracts, review papers, non-english papers and unrelated papers were excluded. Relevant data were collected and analyzed using comprehensive meta-analysis software. Publication bias was assessed for using Egger's test.

RESULTS:

4 case-controls studies examining a total of 4349 patients were included in our analysis. 31.8% of patients with acute pancreatitis were found to have NAFLD. The odds ratio (OR) of SAP in NAFLD compared to non-NAFLD was 2.57 (CI95% 2.15–3.06). No publication bias was noted using Egger's test.

CONCLUSION:

We note NAFLD to be found in about 31.8% of patients presenting with AP. Patients with NAFLD were significantly more likely to develop SAP than controls with OR 2.57 (CI95% 2.15–3.06) indicating a predisposition for SAP in this patient population. While this increase in SAP is likely related to increased pancreatic and peripancreatic fat deposition in NAFLD patients, further research is needed to determine the exact pathophysiology behind this association.
45 The Role of the Biliary and Gut Microbiome in the Progression of Cholangiocarcinoma and Primary Sclerosing Cholangitis
Authors: Katsuyuki Miyabe , Chandrasekhara Vinay , Wongjarupong Nicha , Chen Jun , Johnson Stephen , Chia Nicholas , Gossard Andrea A. , Walther-Antonio Marina , Oli Sharad , Giama Nasra H. , Ali Hamdi A. , Sravanthi Lavu , Hassan Fatima , Ali Hawa , Yao Janet Z. , Harrington Sean C. , Enders Felicity T. , Rizvi Sumera H. , Gores Gregory J. , Topazian Mark D. , Kashyap Purna C. , Roberts Lewis R.
Published: October 2019

INTRODUCTION:

Primary sclerosing cholangitis (PSC) is a chronic, fibroinflammatory, cholestatic liver disease of unknown etiopathogenesis which is recognized as a major risk factor for cholangiocarcinoma (CCA). We aimed to investigate the roles of the biliary and intestinal microflora in the inflammatory process of PSC and to determine if the microflora is associated with progression to CCA.

METHODS:

We studied the bile and stool microbiomes in samples obtained from patients with PSC (31 stool and 35 bile samples), sporadic CCA (11 stool and 26 bile samples), and PSC coexisting with CCA (16 stool and bile 17 samples). Control bile was obtained from patients with cholelithiasis or choledocholithiasis (n = 17). DNA extraction was followed by amplification and high-throughput next generation sequencing (MiSeq) of the 16S rDNA (V3-V5) region to identify the microbiota present. We performed: 1. analysis of the stool microbiome between PSC and CCA patients; 2. analysis of the biliary microbiome in PSC and CCA patients; 3. comparison of the biliary microbiome collected before and after biliary stent placement.

RESULTS:

Although bile samples from study patients had significantly lower sequencing depths than stool, their sequencing depths were much higher than bile from negative controls. The microbiomes of stool and bile samples from the same patients were significantly correlated (P = 0.022). CCA bile samples had significant difference of alpha diversity from control bile samples with less Streptococcaceae and Desulfovibrionaceae (FDR < 10%) than PSC whereas no significant change of stool microbiome was identified between CCA and PSC. Fusobacterium and Gemella were correlated to PSC duration. An increased abundance of Fusobacteria after stent placement was revealed. Fusobacteria, which is inflammation-promoting, was also increased with the number of stents in the bile duct.

CONCLUSION:

Our study suggests that the bile microbiome is potentially a more distinctive biomarker than the stool microbiome for PSC and CCA development. There is increased inhabitance of inflammation-promoting bacteria in the bile of CCA patients and after biliary stent placement. Increased PSC duration also increases the microbial burden in the bile, which may also promote CCA development. We further detected specific bile microbes statistically associated with CCA or stent presence in the bile ducts, which raises the possibility of their role in the CCA progression or stent obstruction. Additional analyses with more samples are needed.
47 Acute Pancreatitis Management Discrepancies Between Different Services in a Single Hospital Setting Affecting Patient Outcomes
Authors: Mohy-ud-din Nabeeha , Deyl Ivana , Umar Shifa , Baki Heitham Abdul , Morrissey Suzanne
Published: October 2019

INTRODUCTION:

In the US, acute pancreatitis (AP) is a leading cause of inpatient care among Gl conditions at an aggregate cost of >$2.6 billion per year. Multiple clinical guidelines exist for AP, however institutional practices vary in adherence to these. Our study compares the management of AP and adherence to published guidelines among teaching and non-teaching medicine services within the same center. Survey-based methods of analysis were performed.

METHODS:

A retrospective chart review of patients with an unplanned admission to a non-ICU hospital ward between Jan 2016–Jan 2017 with primary diagnosis of AP was performed. ICU admissions and hospital transfers were excluded. Clinical and epidemiological data was extracted, and patients were stratified to their respective admitting services: academic teaching medical service and non-teaching hospitalist service. Mean fluid resuscitation was defined as fluids ordered for patient for the first 24–48 hours.

RESULTS:

A total of 75 patients were included in the study. 37% (n = 28) were admitted to a resident teaching service (TS) and 63% (n = 47) to a hospitalist non-teaching service (NTS). Baseline characteristics between the two groups were comparable with similar age, sex, etiology of pancreatitis and BISAP scores (Table 1). The most common cause of acute pancreatitis on the TS and NTS were alcohol induced (35.7%, n = 10) and gallstone pancreatitis (42.5%, n = 20), respectively. 96% of patients (n = 27) admitted to a TS and 25% (n = 12) on NTS had CRP ordered on admission (P = < 0.001). Lactated Ringers was ordered for 68% (n = 19) and 21% (n = 10) of patients on TS and NTS (P = < 0.001), respectively. Mean fluid resuscitation for patients admitted to TS was 153 ± 45 ml/hr compared to 113 ± 43 ml/hr for NTS (P = < 0.001). A Gastroenterology consult was placed for 43% (n = 12) of patients admitted to TS and 75% (n = 35) of NTS (P = 0.008). Length of stay was comparable at 4.85 ± 6.2 and 4.53 ± 4.9 days for TS and NTS, respectively. Details of differences in management between both services are summarized in Table 2.

CONCLUSION:

Wide variability exists in management of patients admitted to different services within the same institution. Significant differences exist in labs ordered, type of fluid ordered on admission, rate of fluid and consultations to the GI team. We aim to target these differences through a multi-faceted quality improvement initiative.
52 Decline in Total Serum Bilirubin Level Is Sensitive but Not Specific Marker for Spontaneous Common Bile Duct Stones Passage
Authors: Al-Ghanoudi Ashirf , Frandah Wesam , Mardini Houssam
Published: October 2019

INTRODUCTION:

Increased serum total bilirubin (T. bili: mg/dl) on presentation is one of the commonly used markers for the presence of common bile duct (CBD) stones. We sought to examine the relationship between the decrease in T. bili level and the probability of spontaneous stone passage in patients (pts) with suspected or confirmed choledocholithiasis.

METHODS:

Pts who were 18 or older and admitted to our institution between October 2015 and December 2017 with ICD 10 code(s) used in pts with confirmed or suspected choledocholithiasis were identified through the University of Kentucky Medical Services Database. Only pts with documented elevated T. bili with at least 3 measurements 12 hours apart were included for further review. Only pts with high-probability of choledocholithiasis based on very strong and/or strong clinical predictors of choledocholithiasis per ASGE guidelines were included in the final analysis. All selected pts underwent one or more of the following confirmatory studies: MRCP, ERCP, EUS or IOC. Categorical variables were compared using chi square tests and continuous variables using two-sample t-tests. Regression analysis was performed to identify independent variables associated with retained stone despite consistent decline in T. bili level.

RESULTS:

825 pts were identified according to the screening criteria. 723 pts were excluded due to having pathologies and 102 pts were included in this study (48 males & 54 females). Mean age of 57.4 years ± 22. 33 pts had fluctuation or no decline in T. bili level and 30 of them (92%) were confirmed to have retained stones. Among the 75 pts with consistent decline in T. bili level after 48 hours from initial presentation, 26 (34.7%) were found to have retained stone while 49 (65.3%) were confirmed to have no retained stones (passed spontaneously). On regression analysis, predictors of the presence of retained CBD stone(s) despite consistent decline in T. bili level included: pts older than 55 (OR 1.9; 95% CI: 1.1, 3.4) and pts presented with severe cholangitis defined as WBC > 16,000 and hypotension (OR 1.6; 95% CI 1.2–2.7).

CONCLUSION:

Although consistent decline in T. bili level is a sensitive predictor for spontaneous CBD stone passage, it is not specific and can be seen in at least one third of patients with documented retained stones. Possible explanations for decreased specificity include vigorous medical support (hydration & antibiotics) that may contribute to decline in T. bili level even in the setting of retained stones.
53 Impact of Insurance Status and Race on Outcomes of Choledocholithiasis With Acute Cholangitis: A Nationwide Analysis
Authors: Sharma Sachit , Khan Zubair , Poudyal Abhushan , Acharya Ashu , Uprety Alok , Ghimire Subash
Published: October 2019

INTRODUCTION:

We examined the impact of insurance and race on in-hospital mortality and time to early ERCP in adult patients with choledocholithiasis with acute cholangitis.

METHODS:

Adult patients with choledocholithiasis with acute cholangitis were selected from the National Inpatient Sample 2016. Primary outcome: in-hospital mortality. Secondary outcomes: Time to early ERCP defined as ERCP performed within 24 hours of hospitalization. We stratified patients based on race and insurance (Medicare, Private insurance, Other-Medicaid, uninsured).

RESULTS:

Mortality was similar for Medicare and private insurance [adjusted odds ratios (aOR): 0.89 95% confidence interval (CI) 0.40 to 2.00), P = 0.796], and for under/uninsured patients [aOR: 1.02 (CI: 0.87 to 1.19), P = 0.76] as well. Compared with Medicare, there was no change in the likelihood of ERCP in patients with private insurance [aOR: 1.21 (CI: 0.98 to 1.50), P = 0.074] or uninsured patients [aOR: 1.02 (CI: 0.87 to 1.19), P = 0.76]. Similarly, compared to Medicare, there was no change in the likelihood of early ERCP in patients with private insurance [aOR: 1.13 (CI: 0.92 to 1.40), P = 0.22], or in uninsured patients [aOR: 1.07 (CI: 0.91 to 1.26), P = 0.38]. Similar analysis was done to look at the impact of race. White race was taken as reference as this was the largest population. Compared with whites, there was no significant difference in in-hospital mortality between blacks [aOR: 1.76 (CI: 0.94 to 3.29), P = 0.073]; Hispanics [aOR: 0.82 (CI: 0.32 to 2.04), P = 0.67] and others. Compared with whites, there was no significant difference in likelihood of ERCP between blacks [aOR: 0.87 (CI: 0.72 to 1.76), P = 0.198]; Hispanics [aOR: 0.94 (CI: 0.77 to 1.15), P = 0.59] and others. However, blacks were less likely to have early ERCP compared to whites [aOR: 0.78 (CI: 0.63 to 0.96), P < 0.05]. Compared to whites, there was no difference in likelihood of early ERCP in other races: Hispanic [aOR: 0.81 (CI: 0.66 to 1.00), P = 0.051].

CONCLUSION:

Insurance and race do not have significant effect on in-hospital mortality, likelihood of ERCP and early ERCP in patients with choledocholithiasis with acute cholangitis. Only significant difference that we found in our study was that blacks were less likely to have ERCP within 24 hours of hospitalization compared to whites. This may be reflective of changes in healthcare delivery due to the impact of the Affordable care act. However, further analysis is needed in more recent data to ascertain the trends.
54 Disparities in the Diagnosis and Treatment of Bile Duct Cancer Among People With Disability: A National Cohort Study in the Republic of Korea
Authors: Kim Seongmin , Kwon Hyeonwoo , Lee Jun Su , Choi Jongwook , Cho Byungha , Park Seon Mee
Published: October 2019

INTRODUCTION:

This study aimed to evaluate the disparity of diagnosis, treatment and prognosis of bile duct cancer (BDC) by the presence, severity and type of disability.

METHODS:

Patients diagnosed with BDC were selected from a cohort, consisted with 1:3 ratio of age- and sex-matched population with or without disability from the National Disability Database, the Korean Central Cancer Registry, and the Korean National Health Insurance claims database. We evaluated the demographics, socioeconomic status, stages, treatment, and survival rates of BDC patients depending on the presence, severity and type of disability.

RESULTS:

The cohort included 15,065 patients with BDC, with a significantly lower rate among people with severe disabilities than people without or with mild disabilities (110.6 vs. 136.5 or 147.6 per 105 persons, respectively). Patients with disabilities had higher Charlson comorbidity index (1.43 vs. 2.00) and more below poverty line (6.0% vs. 11.9%) than those without disabilities. People with severe disabilities were diagnosed BDC at earlier age, but less likely to undergo surgery (adjusted odds ratio 0.52, 95% confidence interval 0.45–0.61) or chemotherapy (0.55, 0.45–0.67) than those without disabilities. This trend was more evident in patients with mental disorders. The overall and cancer specific mortality rates were higher in patients with disabilities than those without disabilities.

CONCLUSION:

In Korea, people with disabilities have a lower rate of BDC diagnosis, receive less surgery or chemotherapy, and have a lower survival rate than people without disabilities. This trend was more evident in patient with severe disabilities and with mental disorders.
58 Prevalence, Trend, and Predictors of Opioid Abuse Among Patients With Chronic Pancreatitis
Authors: Akanbi Olalekan , Adejumo Adeyinka C. , Alayo Quazim A. , Tripathi Nishant , Yarra Pradeep , Kudaravalli Praneeth
Published: October 2019

INTRODUCTION:

Opioids are a mainstay of chronic pain management however their continued use has become a public-health crisis with potential for abuse and associated adverse outcomes. Patients with Chronic Pancreatitis (CP) suffer from recurrent debilitating pain and are thus susceptible to opioid abuse. We aimed to determine the prevalence, trends and determinants of Opioid Use Disorder (OUD) among hospitalized patients with CP.

METHODS:

Patients with OUD were identified in the Healthcare Cost and Utilization Project – Nationwide Inpatient Sample (HCUP-NIS), 2007–2014 and the temporal trend of OUD was analyzed and compared among patients with and without CP. We then extracted patients with a discharge diagnosis of CP from HCUP-NIS 2012–2014 and identified the characteristics of OUD in these patients. Predictors of OUD was evaluated using multivariate logistic regression models (SAS 9.4).

RESULTS:

87,068 patients with a primary diagnosis of CP were identified, of which 3,008 (3.45%) had concomitant OUD. With an average annual increase of 29.4 cases per 10,000 hospitalizations vs. 10.6 cases per 10,000 hospitalizations, the rate of OUD in CP patients is increasing at a steeper rate than patients without CP. Predictors of OUD were young age, females, Medicare or Medicaid insurance, mental health disorders, non-opioid substance abuse and comorbid conditions such as arthritis, back pain and headache. The northeast region, urban and large bed size hospitals also have higher odds of OUD.

CONCLUSION:

OUD affects a significant proportion of patients with CP and occurs at an increasing rate; almost 3 times the rate of those without CP. A better recognition of predisposing pre-existing demographic and clinical variables among at-risk individuals may help guide the utilization of opioids in this patient group, slowing and potentially reversing the rates of OUD.
61 Spontaneous Resolution of Biliary Obstruction in Patients With Acute Gallstone Pancreatitis and Acute Cholangitis: A Retrospective Study in a Single Medical Center
Authors: Mubder Mohamad I. , Hong Annie , Dhindsa Banreet , Saghir Syed , Makar Ranjit , Cross Chad , Ohning Gordon
Published: October 2019

INTRODUCTION:

Spontaneous resolution of biliary obstruction has been reported in a high percentage of patients who present with gallstone acute pancreatitis (AP) and acute cholangitis (AC). Persistent biliary obstruction is associated with significant morbidity and requires urgent endoscopic intervention. Currently, the reported percentage of spontaneous resolution varies widely. Invasive intervention associated with its own risk and complication. Early identification of patients with spontaneous resolution of obstruction can help avoid unnecessary endoscopic intervention.

METHODS:

A retrospective chart review of patients admitted to University Hospital from June 2015 through Dec 2017 with a diagnosis of gallstone AP and AC. ICD-10 codes were used to identify the study cohort (K85.10, K85.11, K85.12, K85.90, K80.32, K80.33, K80.36, K80.37, K80.31). Inclusion criteria include patients with AP (exhibiting 2 out of 3 of abdominal pain, Lipase >3 times the upper limit of normal or features of pancreatitis on imaging with proof of obstruction on imaging) and AC (exhibiting fever, abdominal pain, and jaundice with proof of obstruction on imaging). Data were analyzed temporally using RM-ANOVA with each group as a between-subjects factor; all analyses were completed using SPSS (v. 25).

RESULTS:

Out of 398 patients reviewed, 114 patients were included. 35 patients (30%) demonstrated a stone on imaging and required intervention to relieve the obstruction. 17 (15%) patients showed stone on imaging and demonstrated the spontaneous passage of the stone via ERCP. 62 (54%) patients showed clinical suspicion of spontaneous passage on initial imaging with clinical improvement with or without intervention. No significant differences in characteristics, comorbidities or biochemical markers were identified.

CONCLUSION:

Data from this population-based cohort showed approximately 15% of stones demonstrated on imaging in AP and AC pass spontaneously without intervention. Unlike prior studies done in different populations, no significant difference was found in patients with demonstrated stone between those who required intervention and those who had a spontaneous passage that can help early recognition. A high percentage of patients (54%) showed clinical signs of spontaneous passage of the stone on admission.
65 Comparing Radiation Time in Radiology Technologist-Controlled Versus Endoscopist-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography
Authors: Bou-Abboud Matta Carine , Karb Daniel B. , Ahmad Dina , Chak Amitabh , Glessing Brooke , Faulx Ashley , Dumot John , Isenberg Gerard , Wong Richard C. , Smith Zachary L.
Published: October 2019

INTRODUCTION:

The necessary use of fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) involves radiation exposure to the endoscopy staff and patients. Radiation technologists (RT) are formally trained to minimize exposure whereas endoscopists are not. The aim of this study was to primarily determine whether involvement of RT reduced fluoroscopy time and secondarily to identify independent predictors of increased fluoroscopy time during ERCP.

METHODS:

We conducted a retrospective review of ERCPs performed between August 2017–September 2018 within a single healthcare system. This system is unique in that it has 2 endoscopy units, both of which perform high-volume, high-level ERCPs. Four interventional endoscopists on faculty perform ERCPs at both centers. In one unit (site 1) the fluoroscopy units are controlled by the endoscopist and in the second (site 2) a RT controls it at the direction of the endoscopist. Procedure notes were reviewed for demographic and procedural data. Univariate analyses were used to assess differences among individual variables by site using Chi-squared and Mann-Whitney U test. Secondary comparisons included independent predictors of increased fluoroscopy time as assessed by multivariable linear regression. To minimize confounding, only ERCPs performed by endoscopists who work at both centers were analyzed.

RESULTS:

A total of 949 ERCPs were performed during the study period and 605 met inclusion criteria. Patient demographic and procedure characteristics are outlined in Table 1. There was no significant difference between fluoroscopy times in ERCPs that were RT-controlled (mean 372.7 seconds, st. dev. 391.5) versus endoscopist-controlled (334.2 seconds, st. dev 350.4). When controlling for confounding variables in the multivariable model, this difference remained statistically nonsignificant. Independent predictors of high fluoroscopy time in the multivariable model include trainee involvement, ERCP level 3 complexity, hilar biliary obstruction, technically unsuccessful ERCPs, stent placement, balloon or catheter dilation, mechanical and electrohydraulic lithotripsy, ductoscopy and outpatient procedures (Table 2).

CONCLUSION:

Involvement of a trained RT during ERCP does not decrease fluoroscopy time. Several other fixed and modifiable variables were independently associated with high fluoroscopy times, including trainee involvement. These results stress the importance of formal fluoroscopy education early in an interventional endoscopy fellowship.
67 Appraisal of Follow-up Protocols and Outcomes of High Risk Pancreatic Cancer Surveillance Programs: A Systematic Review and Meta-Analysis
Authors: Chhoda Ankit , Mukherjee Eric , Wattamwar Kapil , Kastrinos Fay , Farrell James J.
Published: October 2019

INTRODUCTION:

Individuals with familial or genetic predisposition are at high risk of pancreatic cancer (PC) and undergo screening. After baseline imaging, these high-risk individuals (HRIs) undergo regular follow-up through cross-sectional imaging, endoscopic ultrasound (EUS), or a combination of these modalities. The follow-up of HRIs is largely based on guidelines, and the evidence and consensus for optimal imaging modality and screening intervals are scarce. The current study is the first systematic review appraising various follow-up strategies among HRIs screened for PC for the detection of new lesions and progression of preexisting abnormalities.

METHODS:

Prospective studies on PC surveillance were analyzed to determine the imaging intervals and predominant modality-Cross sectional imaging: CT or MRI, or Combined EUS and cross sectional imaging. The outcomes of interest included incidence of new lesions where baseline was normal and progression of screen-prevalent lesions, defined as pre-existing abnormalities at baseline imaging. Follow-up was quantified as per 1000 patient-years (pt-yrs). A random effect model was used to calculate cumulative effect measures. The systematic review was performed in adherence with PRISMA guidelines and a preregistered protocol (Figure 1).

RESULTS:

9 uncontrolled studies with 1438 subjects and 6274 pt-yrs of follow-up were analyzed; protocols included cross-sectional imaging (n = 4,4709 pt-yrs), or combined-EUS and cross sectional imaging (n = 5,1565 pt-yrs). HRIs with normal baseline were screened every 12 months, pooled radiologic incidence of 24.74 per 1000 pt-yrs [8.44–48.60, P < 0.01] and diagnostic rate of advanced pathology of 1.06 per 1000 pt-yrs [0–3.99, P < 0.08] (Figure 2). HRIs with screen-prevalent lesions were followed every 3–6 months and longer when stable, with cumulative progression rate of 19.47 per 1000 pt-yrs [1.05–52.98, P < 0.01], and that of advanced pathology-1.54 per 1000 pt-yrs [0–7.55, P < 0.01] (Figure 3). Subgroup analysis showed no significant difference in radiologic incidence or progression or in the histologic diagnosis of advanced pathologies between cross-sectional and combined follow-up protocols.

CONCLUSION:

Surveillance protocols exhibited significantly higher radiologic than histologic diagnostic rates. Though heterogeneity existed between studies, there was no significant difference in the diagnostic rates of incidence or progression between protocols employing predominately cross-sectional vs combined protocols of cross-sectional imaging and EUS.
68 Pancreatic Pseudocysts in Patients With Acute and Chronic Pancreatitis, Trends and Clinical Outcomes of Hospitalization: Insights From a National Inpatient Database
Authors: Mony Shruti , Bertran-Rodriguez Carlos E. , Shah Ishani
Published: October 2019

INTRODUCTION:

Pancreatic pseudocysts are a known sequalae of both acute or chronic pancreatitis and are the most common cystic lesions of the pancreas, accounting for 75%–80% of such lesions. The etiology of which resembles the causes of pancreatitis and is more common after alcohol induced pancreatitis. Although the natural history of the diseases has become clearer with the advent of endoscopic ultrasound, there is limited information on its incidence and trends. The aim of our study was to review demographics and clinical characteristics of patients with pseudocysts and determine the recent trends of the rates of hospitalization and associated health care utilization in patients with pseudocysts related to both acute pancreatitis (AP) and chronic pancreatitis (CP).

METHODS:

A retrospective cross-sectional study of adults (≥18 years) admitted for pseudocyst management (n = 259332) during a five-year period (2010–2014) was performed using the Nationwide Inpatient Sample (NIS). Descriptive analyses were compared using t-test for continuous data and chi-square test for categorical data.

RESULTS:

Over the five-year period, the proportion of patients being admitted for pancreatic pseudocyst has been slowly been increasing (Figure 1) from 19.26 to 21.41 (P < 0.0003. Among the total population, the mean age at admission was 53.4 years, 59.4% were males. Patients with psueodcysts with AP were found to have more risk factors for being overweight and obese compared to CP patients (1.93, 8.9% vs 1.4 and 5.5%, P < 0.001). Overall, inpatient mortality was higher in the AP group (2.38% vs 1.64; P < 0.005); and was associated with a higher length of stay (mean 11.4 days vs 7.3 days). On multivariate analysis, advancing age, morbid obesity, comorbidities like ESRD, congestive heart failure, chronic lung disease, metastatic and pancreatic cancer were associated with increased mortality and length of stay in patients with pseudocysts and acute pancreatitis.

CONCLUSION:

Pancreatic pseudocysts due to acute pancreatitis is associated with an overall higher inpatient mortality, length of stay and cost of hospitalization compared to chronic pancreatitis. Advance age, morbid obesity, comorbidities like ESRD, congestive heart failure, chronic lung disease, metastatic and pancreatic cancer were associated with increased mortality and length of stay in patients with pseudocysts and acute pancreatitis.
69 NanoPac-2017-01 Mid-Study Report: Safety, Tolerability, and Preliminary Efficacy of Intracystic Submicron Particle Paclitaxel (SPP) for the Treatment of Mucinous Cysts
Authors: Othman Mohamed , Tabash Abdalaziz , Verco Shelagh , Verco James , Wendt Alison , diZerega Gere
Published: October 2019

INTRODUCTION:

Pancreatic Mucinous cystic lesions (MCL) have significant potential for malignant transformation; delivery of SPP as a direct intratumoral injection confirmed SPP present at the delivery site for at least 100 days in a prior study; intracystic therapy with SPP may prevent progression to cancer without corresponding systemic toxicities.

METHODS:

Aim: To determine safety and preliminary efficacy of SPP for treatment of MCLs using endoscopic ultrasound Fine Needle Injection (EUS-FNI). Materials and Methods: Subjects with confirmed MCL, based on elevated intracystic CEA and cytology, receive intracystic SPP via EUS FNI at volumes equal to the aspirated cyst fluid volume in sequential cohorts at 6, 10, and 15 mg/mL in a standard “3+3” dose-escalation protocol. The highest dose with acceptable safety and tolerability profile, as determined by a DSMB, will proceed into the second phase of the study; 9 additional subjects will receive two injections of SPP (same dose) 12 weeks apart. Subjects are followed for 6 months for clinical endpoints including: safety and tolerability evaluations, physical examination findings and vital signs; pharmacokinetic analysis of systemic paclitaxel drug levels; and cyst volume response as reported by imaging at 3 and 6 months.

RESULTS:

Nine subjects have been enrolled to date; 5 have completed the study (1 injection). EUS, imaging, CEA and amylase concentration were consistent with branched duct IPMN cyst (BD-IPMN) or MCNs (Table 1). To date, no dose limiting toxicities, serious adverse events related to treatment, or clinically significant blood work (chemistry; hematology; coagulation) or urinalysis have been reported. Adverse events potentially related to SPP include mild, transient abdominal pain/discomfort in 4 subjects and nausea in 2 subjects. Systemic paclitaxel concentration did not exceed 1 ng/mL, and was undetectable at 2 weeks supporting retention of SPP at delivery site. Cyst volumes in 3 of 5 completed subjects reduced by month 6, 2 remained stable (Table 2).

CONCLUSION:

Intracystic SPP appears safe and tolerable when administered at 6, 10, and 15 mg/mL in a volume equal to that of aspirated cyst fluid. Minimal systemic study drug exposure is experienced. No patients developed pancreatitis. Intracystic SPP appears to prevent continued growth of the cysts and may reduce total cyst volume. Subject enrollment to the second phase (2 injections 12 weeks apart) is underway at 15 mg/mL.