Manish Manrai

Outcome of Acute Pancreatic and Peripancreatic Collections Occurring in Patients With Acute Pancreatitis

Objective: To study the outcome of acute collections occurring in patients with acute pancreatitis Background: There are limited data on natural history of acute collections arising after acute pancreatitis (AP). Methods: Consecutive patients of AP admitted between July 2011 and December 2012 were evaluated by imaging for development of acute collections as defined by revised Atlanta classification. Imaging was repeated at 1 and 3 months. Spontaneous resolution, evolution, and need for intervention were assessed. Results: Of the 189 patients, 151 patients (79.9%) had acute collections with severe disease and delayed hospitalization being predictors of acute collections. Thirty-six patients had acute interstitial edematous pancreatitis, 8 of whom developed acute peripancreatic fluid collections, of which 1 evolved into pseudocyst. Among the 153 patients with acute necrotizing pancreatitis, 143 (93.4%) developed acute necrotic collection (ANC). Twenty-three of 143 ANC patients died, 21 had resolved collections, whereas 84 developed walled-off necrosis (WON), with necrosis >30% (P = 0.010) and Computed Tomographic Severity Index score ≥7 (P = 0.048) predicting development of WON. Of the 84 patients with WON, 8 expired, 53 patients required an intervention, and 23 were managed conservatively. Independent predictors of any intervention among all patients were Computed Tomographic Severity Index score ≥7 (P < 0.001) and interval between onset of pain to hospitalization >7 days (P = 0.04). Conclusions: Patients with severe AP and delayed hospitalization more often develop acute collections. Pancreatic pseudocysts are a rarity in acute interstitial pancreatitis. A majority of patients with necrotising pancreatitis will develop ANC, more than half of whom will develop WON. Delay in hospitalization and higher baseline necrosis score predict need for intervention.

Pancreatic fluid collections: What is the ideal imaging technique?

Pancreatic fluid collections (PFCs) are seen in up to 50% of cases of acute pancreatitis. The Revised Atlanta classification categorized these collections on the basis of duration of disease and contents, whether liquid alone or a mixture of fluid and necrotic debris. Management of these different types of collections differs because of the variable quantity of debris; while patients with pseudocysts can be drained by straight-forward stent placement, walled-off necrosis requires multi-disciplinary approach. Differentiating these collections on the basis of clinical severity alone is not reliable, so imaging is primarily performed. Contrast-enhanced computed tomography is the commonly used modality for the diagnosis and assessment of proportion of solid contents in PFCs; however with certain limitations such as use of iodinated contrast material especially in renal failure patients and radiation exposure. Magnetic resonance imaging (MRI) performs better than computed tomography (CT) in characterization of pancreatic/peripancreatic fluid collections especially for quantification of solid debris and fat necrosis (seen as fat density globules), and is an alternative in those situations where CT is contraindicated. Also magnetic resonance cholangiopancreatography is highly sensitive for detecting pancreatic duct disruption and choledocholithiasis. Endoscopic ultrasound is an evolving technique with higher reproducibility for fluid-to-debris component estimation with the added advantage of being a single stage procedure for both diagnosis (solid debris delineation) and management (drainage of collection) in the same sitting. Recently role of diffusion weighted MRI and positron emission tomography/CT with (18)F-FDG labeled autologous leukocytes is also emerging for detection of infection noninvasively. Comparative studies between these imaging modalities are still limited. However we look forward to a time when this gap in literature will be fulfilled.

Endoscopic ultrasound in the diagnosis and management of carcinoma pancreas.

Endoscopic ultrasound (EUS) has become an important component in the diagnosis and treatment of carcinoma pancreas. With the advent of advanced imaging techniques and tissue acquisition methods the role of EUS is becoming increasingly important. Small pancreatic tumors can be reliably diagnosed with EUS. EUS guided fine needle aspiration establishes diagnosis in some cases. EUS plays an important role in staging of carcinoma pancreas and in some important therapeutic methods that include celiac plexus neurolysis, EUS guided biliary drainage and drug delivery. In this review we attempt to review the role of EUS in diagnosis and management of carcinoma pancreas.

Opium-related sphincter of Oddi dysfunction causing double duct sign

Double duct sign where there is a simultaneous dilatation of both the common bile duct (CBD) and pancreatic duct is usually associated with sinister causes like malignancies of pancreatic head or ampulla. Occasionally, benign causes like chronic pancreatitis or sphincter of Oddi dysfunction (SOD) may cause double duct sign. Chronic opium abuse is a rare cause of the double duct sign, and endoscopic ultrasound (EUS) findings of this rare entity have been occasionally reported. We report about a 54-year-old male with a history of chronic alcohol and opioid abuse evaluated for episodes of abdominal pain and found to have opioid-related SOD and improved with biliary sphincterotomy. EUS was done to rule out malignancy and revealed hypoechoic prominence around terminal CBD suggestive of hypertrophied muscle.

265b Ammonia(NH3) -Positron Emission Tomography- Computed Tomography (PETCT) in Acute Pancreatitis

100%, 93.3%. The sensitivity of Level 1 and Level 2 ductal finding was 93.5%, 95%. The accuracy, sensitivity, and specificity of Level 1 serology were 70.4%, 63%, and 94.1%, respectively. The accuracy, sensitivity, and specificity of Level 2 serology were 22.5%, 27.8%, and 5.9%, respectively. Level 1 other organ involvement (OOI) for Type 1 AIP were 12 patients (21.4%), Level 2 OOI for Type 1 AIP were 13 patients (23.2%), and Level 2 OOI for Type 2 AIP was 1 patient (50%). Level 1 histology for Type 1 AIP was 11 patients, and Level 1 histology for Type 2 AIP was 1 patient. All of patients received steroid therapy (100%) showed resolution or improvement of the pancreatic lesion or OOI clinically and morphologically. Conclusions ICDC is the most sensitive in 5 major criteria, and useful to diagnose and classify AIP with Type 1 and Type 2. However, further studies are necessary to investigate whether it is ideal or not with validation the Level 1 and Level 2.

Relook endoscopy predicts the development of esophageal and antropyloric stenosis better than immediate endoscopy in patients with caustic ingestion

Background and aims Early ( < 24 hours) esophagogastroduodenoscopy (EGD) is used to prognosticate mucosal injury after caustic ingestion. We aimed to compare differences in endoscopic grading on EGDs performed on day 5 and day 1 and to assess the impact of relook endoscopy findings on the development of esophageal and/or antropyloric cicatrization. Patients and methods Consecutive patients admitted within 24 hours of caustic ingestion between 2009 and 2014 underwent EGD and had their mucosal changes graded. Injuries of grade ≤ 2a were classified as mild and ≥ 2b were classified as severe. Patients were followed up for the development of cicatrization and managed per protocol. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios (LRs) were calculated to compare day 1 and day 5 EGD findings. Results A total of 62 patients (35 men; mean age 33 ± 15) underwent both day 1 and day 5 EGDs. Antropyloric stenosis developed in 16 patients, esophageal strictures in nine, and four had both esophageal and antropyloric strictures. Compared with day 1 EGD, endoscopic grading of severe injury on day 5 had higher specificity (83 % vs. 65 %), higher PPV (60 % vs. 41 %), and higher positive LR (5.65 vs. 2.66) for predicting the development of esophageal stricture. Similarly, day 5 endoscopic grading had higher specificity (95 % vs. 61 %), higher PPV (88 % vs. 54 %), and higher positive LR (16 vs. 2.5) for predicting the development of antropyloric stenosis. Conclusion Endoscopic assessment on day 5 is a better predictor of esophageal and gastric cicatrization than day 1 EGD, which significantly overestimates the grade of injury.

Mo1340 Does the Site of Fluid Collection Alter the Clinical Course of Acute Pancreatitis? -A Prospective Observational Study

G A A b st ra ct s clear. Methods: Consecutive patients with symptomatic WOPN seen over last 7 months were prospectively included in the study. All the patients underwent EUS, MRI and abdominal ultrasoundwithin two days. On each of these investigations an attemptwas made to determine the site, size and the nature of contents of the WOPN. The echogenic material seen in the collection on EUS and abdominal ultrasound was considered as necrotic debris. On MRI, the hypo intense areas inside the collection on T2 weighted images were taken as solid debris. The solid debris was quantified by two independent observers for all three imaging modalities and the mean was taken as final value. Results: A total of 21 patients were included. There were 16 males (78.9%) and the mean age was 43.5 ± 11.13 years. The etiology was alcohol in 13 and gall stones in 6 patients. The imaging (EUS, MRI and abdominal ultrasound) was done at a mean of 12 ± 13.93 weeks of onset of abdominal pain. On EUS, 8 patients had a solid content of ≤10%, 11 had a content of 10-40% and 2 patients had a solid content of >40%. On MRI, 10 patients were noted to have a solid content of ≤10%, 9 patients had a solid content >10-40% and 2 had content of >40%. On abdominal ultrasound 9 patients had a content of ≤10% while nine patients had a solid content between 10-40%. WON could not be visualized on abdominal ultrasound in 3 patients, two of whom had a high content of solid debris on EUS/MRI. All patients in whom the collections were not visualized on abdominal ultrasound had presented within 6 weeks of onset of disease. All patients with disease duration of >6 weeks had WOPN well visualized on abdominal ultrasound. Conclusion: Trans abdominal ultrasound can help in diagnosis as well as characterization of majority of WOPN collections with comparable accuracy as that of EUS/MRI. However, collections early in the course of disease and with high content of solid debris may be difficult to evaluate on abdominal ultrasound.

Mo1342 Natural History of GI Fistulae in Acute Pancreatitis-A Prospective & Retrospective Analysis

G A A b st ra ct s clear. Methods: Consecutive patients with symptomatic WOPN seen over last 7 months were prospectively included in the study. All the patients underwent EUS, MRI and abdominal ultrasoundwithin two days. On each of these investigations an attemptwas made to determine the site, size and the nature of contents of the WOPN. The echogenic material seen in the collection on EUS and abdominal ultrasound was considered as necrotic debris. On MRI, the hypo intense areas inside the collection on T2 weighted images were taken as solid debris. The solid debris was quantified by two independent observers for all three imaging modalities and the mean was taken as final value. Results: A total of 21 patients were included. There were 16 males (78.9%) and the mean age was 43.5 ± 11.13 years. The etiology was alcohol in 13 and gall stones in 6 patients. The imaging (EUS, MRI and abdominal ultrasound) was done at a mean of 12 ± 13.93 weeks of onset of abdominal pain. On EUS, 8 patients had a solid content of ≤10%, 11 had a content of 10-40% and 2 patients had a solid content of >40%. On MRI, 10 patients were noted to have a solid content of ≤10%, 9 patients had a solid content >10-40% and 2 had content of >40%. On abdominal ultrasound 9 patients had a content of ≤10% while nine patients had a solid content between 10-40%. WON could not be visualized on abdominal ultrasound in 3 patients, two of whom had a high content of solid debris on EUS/MRI. All patients in whom the collections were not visualized on abdominal ultrasound had presented within 6 weeks of onset of disease. All patients with disease duration of >6 weeks had WOPN well visualized on abdominal ultrasound. Conclusion: Trans abdominal ultrasound can help in diagnosis as well as characterization of majority of WOPN collections with comparable accuracy as that of EUS/MRI. However, collections early in the course of disease and with high content of solid debris may be difficult to evaluate on abdominal ultrasound.

Mo1334 Validation and Comparison of the New Severity Classification Systems With Old Atlanta Classification for Severity of Acute Pancreatitis

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.