Ali Fazel

Acute pancreatitis in children

OBJECTIVES:Currently, there is no scoring system for predicting severity in acute pancreatitis in children. Our intent was to evaluate the performance of existing scoring systems in children, to develop a system for children, and to examine the etiology of acute pancreatitis in children.METHODS:A chart review of children with acute pancreatitis was conducted at six centers, three serving as criterion centers and three as validation centers. Ranson and Glasgow scores were calculated for each admission. Additional clinical data were collected, and parameters correlating with severity were incorporated into a new scoring system. Performance characteristics were calculated for each system.RESULTS:A total of 301 admissions were reviewed, 202 in the criterion group and 99 in the validation group. Eight parameters were included in a new scoring system for children. The parameters were as follows: age (<7 yr), weight (<23 kg), admission WBC (>18,500), admission LDH (>2,000), 48-h trough Ca2+ (<8.3 mg/dl), 48-h trough albumin (<2.6 g/dl), 48-h fluid sequestration (>75 ml/kg/48 h), and 48-h rise in BUN (>5 mg/dl). When the cut-off for predicting a severe outcome was set at 3 criteria, the new system had better sensitivity versus Ranson and Glasgow scores (70% vs 30% and 35%, respectively) and a better negative predictive value (91% vs 85% and 85%). The specificity (79% vs 94% and 94%) and positive predictive value (45% vs 57% and 61%) fell slightly.CONCLUSION:The new scoring system performs better in this group than do existing systems.

Clarithromycin vs. furazolidone in quadruple therapy regimens for the treatment of Helicobacter pylori in a population with a high metronidazole resistance rate

The eradication of Helicobacter pylori plays a pivotal role in the treatment of peptic ulcer disease. Metronidazole resistance, common in Iran, is claimed to be a major reason for the failure of metronidazole‐containing regimens. Both clarithromycin and furazolidone are potential alternatives for metronidazole.

Intrapancreatic Ductal Pressure in Sphincter of Oddi Dysfunction

Objectives: It is widely believed that sphincter of Oddi dysfunction (SOD) induces pancreatitis through an increase in intrapancreatic ductal pressure. Animal models have demonstrated that increased intrapancreatic ductal pressure plays a role in the development of pancreatitis. The role of intrapancreatic ductal pressure in SOD-induced pancreatitis has not been investigated in humans. The present study sought to (1) investigate the effect of SOD on intrapancreatic ductal pressure and (2) identify the correlation between elevated intrapancreatic ductal pressure and the presence of pancreatitis. Methods: A total of 263 patients presenting with abdominal pain, acute recurrent pancreatitis, or chronic pancreatitis were studied. Intrapancreatic ductal pressure was measured blindly. Subsequently complete SOM was performed in standard fashion. Results: Intrapancreatic ductal pressure correlated significantly with sphincter of Oddi (SO) basal pressure (correlation coefficient: 0.39, P < 0.01). Individuals with SOD had a significantly higher pressure (19.6 ± 15.9 mm Hg) as compared with those with normal SO motility (11.1 ± 7.9 mm Hg) (P < 0.001). This significant difference was observed in all subgroups (recurrent abdominal pain, acute recurrent pancreatitis, and chronic pancreatitis) (P < 0.01). Patients with acute recurrent pancreatitis or chronic pancreatitis did not show a significant elevation in their intrapancreatic ductal pressures when compared with those with recurrent abdominal pain alone. Conclusions: SOD leads to an increase in intrapancreatic ductal pressure. Increased PD pressure is not the sole determinant for the development of pancreatitis.

Octreotide relaxes the hypertensive sphincter of Oddi: pathophysiological and therapeutic implications

OBJECTIVES:As our understanding of the pathophysiology of sphincter of Oddi dysfunction (SOD) expands, new avenues arise for pharmacological intervention. Recent evidence suggests that SOD results from a loss of myenteric plexus inhibitory neurons resulting in unopposed cholinergic tone. Octreotide inhibits postganglionic cholinergic neurons, and thus we hypothesize that administration of octreotide will decrease sphincteric pressure in individuals with SOD.METHODS:Thirty-eight patients presenting with recurrent abdominal pain and SOD (basal pressure > 40 mm Hg) were studied. The study was prospective, placebo controlled, and blinded. Patient allocation was consecutive. Sphincter of Oddi manometry was performed in standard fashion. The test group (n = 19) received octreotide acetate (100 μg i.v.), and the control group (n = 19) received i.v. saline. Basal, phasic, and duct pressures as well as phasic amplitude and frequency were recorded before and 3 min after the i.v. infusion. Changes in these parameters before and after i.v. infusions were compared.RESULTS:Octreotide caused a statistically significant reduction in peak and basal sphincter of Oddi pressures relative to saline (p < 0.01 and p < 0.001). Octreotide did not significantly affect wave amplitude, wave frequency, or duct pressure.CONCLUSIONS:Octreotide has the potential to be a valuable addition to the armamentarium for the medical management of SOD.

4468 A randomized controlled trial comparing botulinum toxin injection to pneumatic dilatation for treatment of achalasia.

Introduction : Achalasia is a well defined esophageal motor disorder. Available therapeutic options include surgical myotomy, pneumatic dilation, and more recently intrasphincter botulinum injection. Aim: To compare the efficacy of botulinum toxin injection and pneumatic dilatation in the treatment of achalasia. Methods : Thirty-nine consenting symptomatic adults newly diagnosed with achalasia were consecutively enrolled.The diagnosis was established based on clinical, radiologic, endoscopic and manometric criteria. Exclusion criteria included age less than forty, pregnancy, coagulopathy, serious medical illness or malignancy. Patients were randomized to receive either botulinu toxin injection (20 pats.) or pneumatic dilatation (19 pats.).Over a duration of 12 months, efficacy was assessed on the basis of an esophageal symptom score. Symptom scores were evaluated at 1,6 and 12 months. Clinical recurrence was defined as an increase of sympyom score to greater than 50% of baseline. If symptoms recurred, retreatment was administered with a second botulinum toxin injection or a second pneumatic dilatation. Clinical response to retreatment was followed for the remained of 1 year. If symptoms recurred after retreatment the patient was considered a treatment failure. The 1 year incidence of retreatment and treatment failure was estimated by the Kaplan-meier method. Results : The cumulative retreatment rate (relapse after 1 treatment session) was significantly higher in the botulinum toxin group than the pneumatic dilatation group (P Conclusion : Treatment of achalasia with pneumatic dilation is more efficacious than botulinum toxin in providing sustained symptomatic relief over a one-year duration. The efficacy of a single pneumatic dilation is similar to that of two botulinum toxin injection.

Predictors of Endoscopic Therapy Outcome in Orthotopic Liver Transplantation Patients Experiencing Biliary Leak or Stricture

Predictors of Endoscopic Therapy Outcome in Orthotopic Liver Transplantation Patients Experiencing Biliary Leak or Stricture Ali Fazel, Henry Chiu, Shea Ross, Consuelo Soldevila-Pico, Koorosh MoezArdalan, Christopher Forsmark Background: Biliary complications occur after orthotopic transplantation in 1030% of patients. ERCP is the method of choice for diagnosis and treatment. Endoscopic management fails in a significant minority of patients (10-25%) leading to an eventual need for surgical intervention. Predictors of endoscopic therapy outcome would allow the early identification of individuals requiring surgery and the avoidance of protracted and ultimately unsuccessful endoscopic therapy. Aim: This study seeks to identify predictors of the eventual outcome of endoscopic therapy in individuals experiencing biliary complications after OLT. Methods: This study included all patients undergoing OLT patients between January 1994 and December 2001 at the University of Florida who underwent ERCP for the diagnosis and treatment of a biliary leak and/or stricture at. At total of 128 (17%) patients (mean age 6 SD: 52.5 6 12.9, rang: 4 to 73, Male/Female ratio: 1.7) were included, among which 93 (13%) cases were diagnosed to have biliary anastomotic stenosis and 51 (7%) were found to have bile leak. Concomitant stenosis and leak was found in 16 (2%) patients. Result: The outcome of endoscopic therapy was successful in 75% (70) of cases with biliary anastomotic stricture and 73% (37) cases with a bile leak. Patients with biliary stenosis plus leak had a significantly lower rate of success (50%) (p<0.05). Table 1 shows the result of the comparison of the two groups with successful and unsuccessful outcome. Increased age and the presence of concomitant stenosis and leak were significantly associated with an unsuccessful outcome (p<0.05). Sex, race, liver function tests, platelet count andPThadno significant associationwith the outcome.Conclusion: Individuals with concomitant leak and stenosis have a signicantly higher failure rate with endoscopic therapy and might be considered for earlier surgical referal. Lower age was significantly associated with improved outcome.

4662 Octreotide reduces sphincter pressure in sphincter of oddi dysfunction: further support for selective denervation of the sphincter.

Sphincter of Oddi (SO) motility is modulated by inhibitory and excitatory neurons present in its myenteric plexus. The excitatory neurons are predominantly cholinergic while inhibitory neurons produce nitrous oxide and vasoactive intestinal peptide. Octreotide inhibits both groups of neurons. This explains the relatively equivocal effect of octreotide on the normal SO. In SOD evidence suggests a loss of inhibitory neurons while excitatory neurons remain intact. We hypothesize that octreotide can suppress this unopposed cholinergic activity resulting in relaxation of the hypertensive SO. Aim: To determine the effect of octreotide on the hypertensive SO. Methods: 38 patients presenting with recurrent abdominal pain and SOD (basal pressure >40 mm Hg) were studied. SOM was performed in standard fashion. The test group (n=19) received octreotide acetate 100 mg IV while the control group (n=19) received IV saline. Basal, phasic and duct pressure as well as phasic amplitude and frequency were recorded before and 3 minutes after the IV infusion. Changes in these parameters before and after IV infusions were compared. Results:See table. Octreotide caused a statistically significant reduction in basal and peak SO pressure as compared to saline. Conclusions:Relaxation of the hypertensive SO in response to octreotide supports the hypothesis of selective denervation and indicates a potential role for octreotide in the medical treatment of SOD.

3796 A controlled study of the effect of midazolam on the hypertensive sphincter of oddi.

Midazolam HCl (Versed) is increasingly used for conscious sedation in endoscopic sphincter of Oddi (SO) manometry. The effect of medications on normal and abnormal SO motility should be fully characterized if they are to be used during SO manometry (SOM). Controversy exists as to whether midazolam influences SO motility. Aim: To determine the effect of midazolam on the hypertensive SO. Methods: Thirty-six patients presenting with recurrent abdominal pain and sphincter Oddi dysfunction (basal pressure >40 mm Hg) were studied. ERCP and SOM were performed in standard fashion with a perfused triple lumen catheter. The test group (n=18) received 2 mg midazolam IV while the control group (n=18) received IV saline. Basal, phasic and duct pressures as well as phasic amplitude and frequency were recorded before and three minutes after the IV infusion. Changes in these parameters before and after IV infusions were compared. Results: See table below. Midazolam caused a significant reduction in basal and peak SO pressure as compared to saline (16 and 27 mm Hg respectively). Diagnostic concordance (abnormal vs. normal) of the basal sphincter pressure before and after midazolam was seen in only 83% of patients. Conclusions: Midazolam significantly decreased basal and peak pressures of the hypertensive SO. This effect was clinically significant in that it would have altered diagnosis and management in 3 of 18 patients.We propose that midazolam not be used when sedating patients for sphincter of Oddi manometry.