Amitasha Sinha

Systematic review with network meta‐analysis: pharmacological prophylaxis against post‐ ERCP pancreatitis

The efficacy of many pharmacological agents for preventing post‐ERCP pancreatitis (PEP) has been evaluated in randomised controlled trials (RCTs), but it is unclear which agent(s) should be used in clinical practice. Network meta‐analyses of RCTs are used to simultaneously compare several agents to determine their relative efficacy and identify priority agents for comparison in future RCTs.

An Overview of the Diagnosis and Management of Nutrition in Chronic Pancreatitis

Chronic pancreatitis is characterized by long-standing inflammation of the pancreas, which results in fibrosis and the gradual loss of pancreatic function. The loss of islets and acinar cells results in diabetes and exocrine insufficiency, respectively. Exocrine insufficiency can result in maldigestion of fat, protein, and carbohydrate as well as vitamins and minerals. Patients may present with variable severity of disease, from mild to severe. The diagnosis of chronic pancreatitis can be challenging, especially in patients with early or mild disease who have few to no morphologic abnormalities on standard abdominal imaging studies. A number of imaging modalities and tests have evolved to aid in the diagnosis of chronic pancreatitis based on changes in structure or function. Clinicians typically focus on treating pain in chronic pancreatitis as opposed to exocrine insufficiency, despite the fact that maldigestion and malabsorption can result in nutrition deficiencies. The aims of this review are to describe the various modalities used to diagnose chronic pancreatitis, to illustrate the nutrition deficiencies associated with exocrine insufficiency, and to provide an overview of nutrition assessment and treatment in these patients.

The treatment of venous malformations with percutaneous sclerotherapy at a single academic medical center

Purpose We report a retrospective analysis of venous malformation patients treated with percutaneous sclerotherapy, describing their clinical manifestations, therapeutic outcomes and procedural complications. Materials and methods We reviewed our Vascular Anomalies database for all patients who underwent percutaneous sclerotherapy for venous malformation between January 2005 and July 2011 and retrieved 186 patients, out of which 116 were included in the final analysis. The majority of patients were treated using 100% alcohol (72%) and the rest were treated with <100% alcohol, Sodium Tetradecyl Sulfate or combination of these therapies. The most common location was the lower extremity in 67 patients (58%), followed by the head and neck in 27 (23%) and the upper extremity in 11 (9%). Retrospective review of medical records was performed. Outcomes were classified on an improvement scale based on clinical therapeutic effects. Results Two-hundred and forty-five sclerotherapy procedures were performed in 116 patients, of which 52 patients (45%) underwent a single procedure, 32 (28%) had two procedures and 32 (28%) underwent ≥3 procedures. Median follow-up period from the last procedure was 2.5 months (interquartile range of 2.0 to 6.75 months). Significant improvement was seen in 37 patients (32%), moderate improvement in 31 (27%), mild improvement in 20 (17%), no improvement in 21 (18%) and worse than before in 7 (6%) patients. Major post-procedural complications were nerve injuries in 6 patients (5%), deep vein thrombosis in 5 (4%), muscle contracture in 2 (2%), infection in 3 (3%), skin necrosis in 4 (3%) and other complications in 3 (3%). Conclusion Our study demonstrated that 76% of our patients with venous malformation had some level of improvement in symptoms with majority (72%) undergoing only one or two percutaneous sclerotherapy procedure/s. Although major complications occurred in 20% of the patients, majority (74%) of the complications either resolved spontaneously or were successfully treated.

An international multicenter study of early intravenous fluid administration and outcome in acute pancreatitis

Aims Early aggressive fluid resuscitation in acute pancreatitis is frequently recommended but its benefits remain unproven. The aim of this study was to determine the outcomes associated with early fluid volume administration in the emergency room (FVER) in patients with acute pancreatitis. Methods A four-center retrospective cohort study of 1010 patients with acute pancreatitis was conducted. FVER was defined as any fluid administered from the time of arrival to the emergency room to 4 h after diagnosis of acute pancreatitis, and was divided into tertiles: nonaggressive (<500 ml), moderate (500 to 1000 ml), and aggressive (>1000 ml). Results Two hundred sixty-nine (26.6%), 427 (42.3%), and 314 (31.1%) patients received nonaggressive, moderate, and aggressive FVER respectively. Compared with the nonaggressive fluid group, the moderate group was associated with lower rates of local complications in univariable analysis, and interventions, both in univariable and multivariable analysis (adjusted odds ratio (95% confidence interval): 0.37 (0.14–0.98)). The aggressive resuscitation group was associated with a significantly lower need for interventions, both in univariable and multivariable analysis (adjusted odds ratio 0.21 (0.05–0.84)). Increasing fluid administration categories were associated with decreasing hospital stay in univariable analysis. Conclusions Early moderate to aggressive FVER was associated with lower need for invasive interventions.

Early Predictors of Fluid Sequestration in Acute Pancreatitis: A Validation Study.

Objectives The primary aim of this retrospective study was to externally validate predictors of increased fluid sequestration at 48 hours (FS48) in acute pancreatitis (AP). Methods Patients admitted between January 10 and February 13 with a diagnosis of AP were evaluated. The FS48 was calculated as difference between total fluid input and output in the first 48 hours. Predictors of FS48, such as young age, alcoholic etiology, hemoconcentration, hyperglycemia, and systemic inflammatory response syndrome (SIRS), and outcomes in AP, such as increased length of stay, acute fluid collection(s), necrosis, and persistent organ failure (POF), were defined in accordance with the previous study. Linear regression analysis was performed to evaluate the association between predictors and outcome. Results Two hundred twenty-seven AP patients (mean age, 48 years; 54% men) with a median FS48 of 4.2 L were evaluated. Age younger than 40 years, alcoholic etiology, hemoconcentration, and SIRS independently predicted increased FS48 (P < 0.05). Increased FS48 was associated with persistent SIRS and POF (P < 0.01). There was a significant trend between number of predictors and FS48 (P < 0.001). The presence of 4 predictors or more was associated with higher rates of persistent SIRS and POF (P < 0.01). Conclusions Our study validated 4 of 5 predictors of increased FS48 from the previous study. Presence of 4 predictors or more and increased FS48 are both associated with persistent SIRS and POF.

Persistent SIRS and acute fluid collections are associated with increased CT scanning in acute interstitial pancreatitis

Abstract Background: The use of computed tomography (CT) in acute pancreatitis (AP) continues to increase in parallel with the increasing use of diagnostic imaging in clinical medicine. Aim: To determine the factors associated with obtaining >1 CT scan in acute interstitial pancreatitis (AIP). Methods: Demographic and clinical data of all adult patients admitted between 1/2010 and 1/2015 with AP (AP) were evaluated. Only patients with a CT severity index (CTSI) ≤ 3 on a CT obtained within 48 h of presentation were included. Results: A total of 229 patients were included, of whom 206 (90%) had a single CT and 23 (10%) had >1 CT during the first week of hospitalization. Patients undergoing >1 CT had significantly higher rates of acute fluid collection (AFC), persistent SIRS, opioid use ≥4 days, and persistent organ failure compared to those undergoing 1 CT (p < .05 for all). On multivariable analysis, only persistent SIRS (OR = 3.6, 95% CI 1.4–9.6, p = .01) and an AFC on initial CT (OR = 3.5, 95% CI 1.4–9, p = .009) were independently associated with obtaining >1 CT. Conclusion: An AFC on initial CT and persistent SIRS are associated with increased CT imaging in AIP patients. However, these additional CT scans did not change clinical management.

Length of stay overestimates severity of post-ERCP pancreatitis: Is it time to revise the consensus definition?

Introduction  Length of stay (LOS) is an important determinant of the severity of post-ERCP pancreatitis (PEP) in the consensus definition. The aim of our study was to evaluate and compare severity of PEP based on the revised Atlanta classification (RAC) and the consensus definition. Patients and methods  Between 1/2000 and 12/2011, all adult patients admitted with suspicion of PEP after outpatient ERCP were evaluated. PEP was defined using the RAC, but the severity of PEP was defined using both revised Atlanta and consensus definitions. Results  A total of 341 patients (mean age 49 years and 75 % females) were diagnosed with PEP. The consensus definition classified 57 %, 37 %, and 8 % of patients with mild, moderate, and severe PEP, respectively. The RAC diagnosed 94 %, 6 %, and 0 % with mild, moderate, and severe acute pancreatitis, respectively. Of the patients diagnosed with moderate-severe PEP by consensus definition, only 12.5 % had clinical parameters of pancreatitis severity, such as acute fluid collection(s), pancreatic necrosis, transient organ failure and/or required percutaneous or surgical drainage, while 87.5 % were classified only based on a LOS ≥ 4 days. The most common reason for increased LOS was persistent post-procedural abdominal pain in 47 % of patients, followed by other reasons not related to pancreatitis in 17 %. Conclusion  The consensus definition overestimates the rates of severe PEP when compared to the RAC. The majority of PEP patients classified as moderate-severe PEP have extended LOS, due to post-procedural abdominal pain rather than complications of PEP.

Mo1818 Effect of Aging on the Fecal Microbiome in Healthy Donors for Fecal Microbiota Transplant

Background: Fecal microbiota transplant (FMT) is fast emerging as a promising therapy for recurrent clostridium difficile colitis in patients not responding to antibiotic therapy. However all patients for FMT need a fecal sample from a healthy donor. However the effect of age on the fecal microbiome of the healthy donor and its clinical efficacy, has not been examined previously. Aim: To examine fecal samples of healthy human subjects of various ages, volunteering to donate their samples for FMT by genomic analysis and clinical outcom. Methods: All healthy subjects who were rigorously screened for infectious disease and selected as donors for FMT were included in the study. Fecal samples were processed and analyzed using 16S rRNA gene amplicon sequencing. Microbiota compositions were studied using standard 16S rRNA analysis tools (CloVR-16S). Differences in bacterial phylum abundance and diversity (Shannon index) of the donor fecal microbiota were analyzed using three different cutoff for age of 50 years, 60 years and 70 years. Effect of fecal microbiota from donors of different age groups on efficacy of FMT in patients with RCDI was monitored in the GI clinic. Results: Fecal microbiota of 30 healthy donors was analyzed. The mean age of the donors was 50±15.3 years and ranged between 20 years to 82 years. Of these 30 donors, 18 (60%) were males and 26 (87%) were related to the recipients. The Shannon index did demonstrate significant increase in the fecal microbiome diversity in 70+ year old donors, as demonstrated in Figure 1. Althoughmicrobiome dissimilarity between the younger donors groups was relatively larger than the older donors groups on weighted UniFrac metric analysis, the association was not statistically significant. At phylum level, while the relative abundance of Firmicutes was higher in older groups (p<0.05), Actinobacteria was higher in younger groups (p<0.05). At family and genus level, the relative abundance of bifidobactericeae members were higher in younger group of donors than older group (p<0.05). However, despite these genomic differences in the fecal microbiota with ageing, all of our patients recovered completely from the recurrent clostridium difficile infection. Conclusion: This data suggests that there is a trend towards increase in relative abundance of Firmicutes with ageing. Furthermore the younger subjects were more dissimilar by measuring phylogenetic distances than the older donors. These observations indicate that human fecal microbiome evolves with ageing process and associated factors.

Mo1335 Systemic Inflammatory Response Syndrome (SIRS) in Acute Pancreatitis (AP): Outcome of Early Fluid Therapy

Background Two new classification systems for the severity of acute pancreatitis (AP) have been proposed recently, the determinant based classification (DBC) and revised Atlanta classification (RAC). We aimed to validate and compare these classification systems with original Atlanta classification (OAC). Aims To validate and compare the DBC and RAC with original Atlanta classification (OAC) Methods 469 adult patients with AP admitted to a tertiary care center from January 2009-June 2013 were included in the study. The new classification systems were validated and compared in terms of outcomes (need for interventions, total hospital and intensive care unit (ICU) stay and mortality). Results The mean age of patients was 39.9±13.4 years (331 males) with the commonest etiology being alcohol (161, 34.3%) followed by gall stones (125, 26.6%). There were 119 (25.4%) patients with mild and 250 (74.6%) patients with severe AP as per OAC. Pancreatic necrosis was present in 66.1% and infected pancreatic necrosis in 23.1% patients. 126 (26.9%) patients underwent interventions (endoscopic n= 49, 10.4%, radiological n=95, 20.2% and surgical n=47, 10%). 93 (19.8%) patients died. As per DBC, 97(20.7%), 172 (36.7%), 152 (32.4%), and 48(10.2%) patients were determined to have mild, moderate, severe, and critical AP, respectively. As per RAC, 119 (25.4%), 160 (34.1%), and 190 patients (40.3%) were determined to have mild, moderately severe, and severe AP, respectively. Higher grades of severity were associated with worse outcomes in DBC, RAC and OAC. Predictive accuracies were evaluated using area under the receiver operator characteristics curve (AUROC) and Somers D co-efficient. The DBC, RAC and OAC were comparable in predicting the need for interventions (AUROC 0.53, 0.55, 0.54, p=0.36) and length of hospital stay (Somers D, 0.27, 0.26, 0.23, p=0.41). However, both DBC and RAC had comparable but better accuracy than OAC in predicting need for ICU admission (AUROC 0.73 for both vs. 0.62 for OAC, P<0.001), length of ICU stay (Somers D, 0.35 for both vs. 0.24 for OAC, p<0.001) and mortality (AUROC 0.78 for both vs. 0.61 for OAC, p<0.001). Conclusion Determinant based classification and revised Atlanta classification categorize patients into subgroups that reflect clinical outcomes. Both have comparable and higher predictive accuracy than old Atlanta classification for need for ICU admission, length of ICU stay and mortality.