Veeral M. Oza

Morbid Obesity Is Associated With Adverse Clinical Outcomes in Acute Pancreatitis: A Propensity-Matched Study.

OBJECTIVES:Morbid obesity may adversely affect the clinical course of acute pancreatitis (AP); however, there are no inpatient, population-based studies assessing the impact of morbid obesity on AP-related outcomes. We sought to evaluate the impact of morbid obesity on AP-related clinical outcomes and health-care utilization.METHODS:The Nationwide Inpatient Sample (2007–2011) was reviewed to identify all adult inpatients (≥18 years) with a principal diagnosis of AP. The primary clinical outcomes (mortality, renal failure, and respiratory failure) and secondary resource outcomes (length of stay and hospital charges) were analyzed using univariate and multivariate comparisons. Propensity score-matched analysis was performed to compare the outcomes in patients with and without morbid obesity.RESULTS:Morbid obesity was associated with 3.9% (52,297/1,330,302) of all AP admissions. Whereas the mortality rate decreased overall (0.97%0.83%, P<0.001), it remained unchanged in those with morbid obesity (1.02%1.07%, P=1.0). Multivariate analysis revealed that morbid obesity was associated with increased mortality (odds ratio (OR) 1.6; 95% confidence interval (CI) 1.3, 1.9), prolonged hospitalization (0.4 days; P<0.001), and higher hospitalization charges (

Rapid acquisition technique for MR elastography of the liver.

5,067; P<0.001). A propensity score-matched cohort analysis demonstrated that the primary outcomes, acute kidney failure (10.8 vs. 8.2%; P<0.001), respiratory failure (7.9 vs. 6.4%; P<0.001), and mortality (OR 1.6, 95% CI 1.2, 2.1) were more frequent in morbid obesity.CONCLUSIONS:Morbid obesity negatively influences inpatient hospitalization and is associated with adverse clinical outcomes, including mortality, organ failure, and health-care resource utilization. These observations and the increasing global prevalence of obesity justify ongoing efforts to understand the role of obesity-induced inflammation in the pathogenesis and management of AP.

Proximal Serrated Polyp Detection Rate Correlates with Adenoma DetectionRate and is Impacted by Mean Withdrawal Time: A Retrospective Study

Magnetic resonance elastography (MRE) of the liver is a novel noninvasive clinical diagnostic tool to stage fibrosis based on measured stiffness. The purpose of this study is to design, evaluate and validate a rapid MRE acquisition technique for noninvasively quantitating liver stiffness which reduces by half the scan time, thereby decreasing image registration errors between four MRE phase offsets. In vivo liver MRE was performed on 16 healthy volunteers and 14 patients with biopsy-proven liver fibrosis using the standard clinical gradient recalled echo (GRE) MRE sequence (MREs) and a developed rapid GRE MRE sequence (MREr) to obtain the mean stiffness in an axial slice. The mean stiffness values obtained from the entire group using MREs and MREr were 2.72±0.85 kPa and 2.7±0.85 kPa, respectively, representing an insignificant difference. A linear correlation of R(2)=0.99 was determined between stiffness values obtained using MREs and MREr. Therefore, we can conclude that MREr can replace MREs, which reduces the scan time to half of that of the current standard acquisition (MREs), which will facilitate MRE imaging in patients with inability to hold their breath for long periods.

Asymptomatic Duodenal Perforation from an Inferior Vena Cava Filter

Background: Given the implicated role of proximal serrated polyps (PSP) in the development of interval colon cancer, it is important to investigate if proximal serrated polyp detection rate (PSPDR) correlates with adenoma detection rate (ADR) and the factors that are associated with higher detection rates. Methods: We performed a retrospective review of medical records of average-risk patients who underwent a screening colonoscopy at a tertiary care academic center. A total of 851 screening colonoscopies were analyzed. Results: Gastroenterologists (n=22) performed the 851 colonoscopies. In univariable logistic regression, endsocopists with a mean WT ≥11 minutes had a higher odds of detecting a PSP compared to endoscopists with a mean withdrawal time WT <11 minutes (p<0.001; OR 5.3; 95% CI 2.6-10.8). Odds of PSP detection were greater in males than females (p=0.01; OR 2.2; 95% CI 1.2-4.1). The multivariable regression analyses confirmed that PSPDR was higher for endoscopists with mean WT ≥11 minutes (p<0.001). In addition, there was a significant correlation between ADR and PSPDR among endoscopists who performed at least 50 colonoscopies during the study period (r=0.89, p=0.04). Conclusions: We concluded that there is a strong correlation between PSPDR and ADR and that a mean WT ≥11 minutes is an independent predictor of higher PSPDR.

Special Considerations for the Gastroenterologist

Recent exponential increase in inferior vena cava (IVC) filter placements has led to a higher rate of filter complications. A 46-year-old man with a past history of IVC filter placement for bilateral deep vein thrombosis presented with lower abdominal pain. Imaging studies demonstrated IVC filter strut penetrations into multiple structures. Upper endoscopy confirmed an uncomplicated single IVC filter strut penetration into the duodenal wall. The abdominal pain was determined to be unrelated to IVC filter strut penetration, and the patient was managed conservatively. Although IVC filter strut penetrations can cause significant complications, current guidelines remain unclear for management of asymptomatic enteric IVC filter strut penetrations.

Double pylorus sign.

As rates of obesity rise, the incidence of common bile duct stones (CBDS) is expected to increase. As such, current knowledge of the management of these stones and their subsequent complications is vital for any gastroenterologist. Endoscopic treatment is now standard for management of CBDS. In some special circumstances, surgical management or a combined endoscopic and surgical approach may be necessary. We highlight the key issues within specific clinical scenarios which may alter management. We discuss the approach to patients with post-surgical anatomy, acute cholangitis, acute gallstone-mediated pancreatitis and patients with inherited or acquired coagulation disorders. The specific techniques of different surgical and endoscopic procedures will be covered in different chapters of the book.

Intratumoral endoscopy and diagnosis of a large gastrointestinal stromal tumor.

The double pylorus (DP) sign is a rare endoscopic finding, with an estimated prevalence of ~0.04 %, usually in patients with a history of peptic ulcer disease (PUD) [1]. This condition is treated with proton pump inhibitors (PPI), and closure of the acquired pylorus has been described [2]. Although this finding can be congenital, a history of increased non-steroidal anti-inflammatory drug (NSAID) use is often elicited, making an acquired etiology the likely diagnosis. The DP finding does not have pathognomonic signs or symptoms, and is often an incidental finding of endoscopy. In some cases, the defect is detectable on radiographic contrast studies as two distinct conduits [1]. Most reported cases of DP arise from gastric ulcers in the antrum of the stomach; rarer yet are reports of this complication from duodenal or gastric cancers [2]. The accompanying image is from a 78-year-old man with a history of PUD, metastatic prostate cancer, and complaints of back pain, fatigue, and melena. Laboratory evaluation revealed anemia with hemoglobin of 6.4 g/dL. Upper gastrointestinal endoscopy revealed an ulcer in the duodenal bulb and the DP sign within the gastric antrum (Fig. 1). Patient was counseled to avoid all NSAIDs and to use daily PPI indefinitely.

Tu1912 Determining Novel Clinicopathologic Correlations of High Grade Pancreatic Intraepithelial Neoplasia (PanIN) in Pancreatic Ductal Adenocarcinoma (PDAC)

Gastrointestinal tumors represent less than 1 % of all gastrointestinal (GI) tract cancers; however, they constitute the most common type of mesenchymal neoplasm of the GI tract. These tumors are known to arise from the interstitial cells of Cajal and are characterized by CD117 (c-kit) and CD34 positivity on immunohistochemistry [1, 2]. About 20–30 % of gastrointestinal stromal tumors (GISTs) undergo malignant transformation [3]. The incidence of GISTs is 3,300 to 6,000 new cases per year in the United States, and they commonly originate in the stomach (60 %) and rarely in the duodenum (5 %) [4]. The common clinical presentations include GI bleeding and abdominal pain [5]. Fistulization of a GIST into the duodenal lumen is extremely rare with only one prior report in literature, where the fistula was identified postoperatively [6]. To our knowledge, this is the first report of intratumoral endoscopy through a fistulous tumor tract for diagnosis of a GIST. Case

Tu1301 Predictors of Severe Dysplasia in Surgically Resected Non-Malignant Intraductal Papillary Mucinous Neoplasms (IPMN)

Background: Pancreatic cancer has an extremely poor prognosis. At the time of diagnosis, over 80% of patients have locally advanced or invasive disease. The carcinogenesis of pancreatic ductal adenocarcinoma (PDAC) involves stepwise progression from pancreatic intraepithelial neoplasia (PanIN) to invasive carcinoma. PanINs measure less than 5 mm and are not detectable on current imaging modalities. Precursor lesions, such as high-grade PanIN (PanIN-3) represent a target for early intervention. Low grade PanIN-1 and -2 are widely prevalent but their significance is unclear. Aims: To evaluate prevalence, significance and implications of PanIN-3 in PDAC. Methods: A retrospective review of the pathology database (1/2000 to 7/2013) at a tertiary care center. Demographic information, patient history, imaging studies, EUS findings and surgical pathology were reviewed. Results: A total of 607 pancreatic resections for cystic and solid lesions were reviewed. Neoadjuvant chemotherapy was given to 48 patients. In the remaining 559 patients, 198 (35.4%) had primary surgical resection for PDAC. Among these patients, 74.5% (of 185) showed the presence of any subtype of PanIN. High grade or PanIN-3 was present in 36.2% (of 185) resections for PDAC. Further, PanIN-3 was mostly found in PDAC (90.5%, p-value <0.001) compared to all other lesion types. Among patients with PDACs, who did not receive neoadjuvant therapy, univariate analysis (tables 1 and 2), demonstrated that Caucasian race and the presence of perineural invasion were significantly associated with PanIN-3. Pathological evidence of chronic pancreatitis and higher number of positive lymph nodes trended towards significant. Using these variables in a binomial logistic regression model demonstrated that Caucasian race (OR 10.9, p-value 0.02, 95% confidence interval 1.4, 86.6) and the presence of perineural invasion (OR 6.4, p-value 0.02, 95% confidence interval 1.4, 29.2) were significantly associated with PanIN-3. Interestingly, a comparison of PanIN3 among PDACs who underwent primary surgical resection versus post-neoadjuvant chemotherapy resection revealed that there was an absence of significant reduction in PanIN-3 among post-neoadjuvant resected PDACs (66 of 168 (39.3%) vs. 12 of 36 (33.3%), p = 0.57). Conclusion: High grade PanIN lesions are particularly prevalent in PDACs. In patients undergoing primary surgical resection for PDACs, high grade PanIN-3 lesions were notably associated with Caucasian race and perineural invasion. Supporting prior literature that PanIN-3 lesions may harbor cells with invasive features, the finding of PanIN-3 association with perineural invasion needs to be validated by larger studies. Table 1. Univariate analysis of clinicopathologic categorical variables of PanIN-1 and -2 vs. PanIN-3

Tu1303 Risk of Adenocarcinoma in Resected Intraductal Papillary Mucinous Neoplasm (IPMN) With Involvement of the Main Pancreatic Duct (MD)

Background & Aims: Endoscopic ultrasound (EUS) is often used as the gold standard to diagnose chronic pancreatitis (CP) despite concerns about its intra-operator reliability and validity. We sought to determine the benefit of repeat EUS in patients suspected of having CP but having an equivocal or negative initial EUS exam for CP. Methods: Patients who underwent at least two EUS exams at our medical center to evaluate for CP from 20012012 were identified. Demographic, procedural and etiologic factors were abstracted via chart review. Specifically, EUS minimal standard criteria (MST) for CP (hyperechoic foci, hyperechoic strands, lobularity, cysts, ectatic duct, hyperechoic ductal wall, dilated side branches, ductal stones, ductal dilation) were abstracted for all exams. Diagnosis of CP was based on physician impression following each EUS. Results: Between the first and second EUS exams, the number of patients diagnosed with CP increased from 49% to 76% (p<0.01). Additionally, the number of patients with an indeterminate diagnosis after the first exam decreased significantly after the second exam (41% vs 21%, p<0.01). The presence of hyperechoic foci increased on the second exam (50% vs. 68%, p=0.04), but no other parenchymal or duct features were found to reliably increase. On subgroup analysis, significant increases in hyperechoic foci identified on repeat EUS were found in women (43% vs 67%, p=0.03), patients under the age of 50 (47% vs 74%, p<0.02) and patients in whom recurrent acute pancreatitis is the etiology of their CP (18% vs 73%, p=0.03). Conclusions: Serial EUS exams are valuable in patients with indeterminate prior EUS exams in whom the diagnosis of CP is not secure. In particular, women and those <50 years old appear to benefit the most from serial evaluation.