Diagnoses Of Acute Pancreatitis Research Articles

Modified Bedside Index for severity in acute pancreatitis (BISAP) score validation in the national inpatient sample database

PurposeThe aim of this study was to build and validate modified score to be used in the healthcare cost and utilization project databases for further classification of acute pancreatitis (AP). Materials and methodsThe National Inpatient Sample database for the years 2016-2019 was queried for all primary adult discharge diagnoses of AP. An mBISAP score system was created utilizing the ICD-10CM codes for pleural effusion, encephalopathy, acute kidney injury, systemic inflammatory response, and age >60. Each was assigned a 1-point score. A multivariable regression analysis was built to test for mortality. Sensitivity and specificity analyses were performed for mortality. ResultsA total of 1,160,869 primary discharges for AP were identified between 2016 and 2019. The pooled mortality rate was: 0.1%, 0.5%, 2.9%, 12.7%, 30.9% and 17.8% (P ​< ​0.01), respectively for scores 0 to 5. Multivariable regression analysis showed increasing odds of mortality with each one-point increment: mBISAP score of 1 (adjusted odds ratio [aOR] 6.67; 95% confidence interval [CI] 4.69-9.48), score of 2 (aOR 37.87; 95% CI 26.05- 55.03), score of 3 (aOR 189.38; 95% CI 127.47-281.38), score of 4 (aOR 535.38; 95% CI 331.74-864.02), score of 5 (aOR 184.38; 95% CI 53.91-630.60). Using a cut-off of ≥3, sensitivity and specificity analyses reported 27.0% and 97.7%, respectively, with an area under the curve (AUC) of 0.811. ConclusionIn this 4-year retrospective study of a US representative database, an mBISAP score was constructed showing increasing odds of mortality with each 1-point increase and a specificity of 97.7% for a cut-off of ≥3.

Epidural Analgesia for Pain Management in Acute Pancreatitis during Pregnancy and Its Effect on Maternal and Fetal Outcome.

Background Acute pancreatitis (AP) during pregnancy is a rare presentation with an estimated incidence of 1 case per 1000 to 10,000 pregnancies. Severe epigastric and abdominal pain is the earliest and the most common symptom of AP, and adequate pain relief is an integral part of patient management. The aim of our study was to investigate the different pain relief modalities that are used in pregnant women with AP and the efficacy of each method used, in terms of better pain relief and maternal-fetal outcomes. Methods This was a retrospective observational study over a period of 6 years conducted at a tertiary care hospital. Pregnant women with clinical and biochemical diagnoses of acute pancreatitis were included in the study. Patient's history and clinical and biochemical data were collected from the medical records of the hospital. Results A total of 12 patients were included in the study, 5 out of 12 patients had gall stones associated with AP, 2 patients had hypertriglyceridemia, and 1 each had preeclampsia and eclampsia. Epidural analgesia at the level of L1-L2 spinal level showed a reduction of VAS scores from 8 or 9 to 1 or 2, indicating excellent pain as compared to t intravenous (i/v) infusion of fentanyl or i/v boluses of injection tramadol, in whom VAS was never reduced below 3. With satisfactory results, labour analgesia and anesthesia for caesarean section was provided via the same catheter in 2 and 3 patients, respectively. Maternal and fetal outcomes were comparable in all the patients. Conclusion AP in pregnancy, when diagnosed early and managed accordingly, leads to better maternal and fetal outcomes. Epidural analgesia was better than intravenous analgesia in terms of pain management and better recovery of acute pancreatitis patients. In these patients, labour analgesia and anesthesia for caesarean section can be provided through the same catheter, making it a potential novel modality in the treatment of acute pancreatitis in pregnancy.

P-P04 The cost of acute pancreatitis is amylasing!

Abstract Background Amylase is the key serum biomarker in the diagnosis of acute pancreatitis, however there is no indication for repeat/serial measurement once the diagnosis is established. It is estimated that £27,000pa is spent unnecessarily on repeat amylase investigations without clinical indication1. Anecdotally, within the department, unnecessary repeats were being routinely performed. Resultantly, we audited in 2019 and 2020 to understand the extent of the issue. Following the first cycle, pre-rotation departmental talks were given to all relevant healthcare staff. Aim(s) Methods Data was collected and analysed retrospectively over 2 audit cycles (C1 &amp; C2) from 79 patient episodes of admissions to the surgical department of a Northern Major Trauma Centre with confirmed diagnoses of acute pancreatitis between 01/05/2019 – 31/07/2019 and 01/08/2020 – 31/12/2020. Resources used included: patient notes, IMPAX and WebICE. Data was collected and analysed by one author in C1 but multiple authors in C2. Results Mean age = 60 years. Male:Female ratio was 8:16 and 24:31, respectively. Initial amylase was diagnostic in &amp;gt; 75% (61/79). 81 unnecessary repeats performed. Most patients underwent imaging (75% and 67%) however, only approximately one-third (30.8% and 32.4%) of scans were performed to confirm the diagnosis. • Despite imaging confirming the diagnosis in 88%, &amp;gt;50% of imaged patients had repeat amylase testing. Conclusions The results demonstrate that our intervention, a pre-rotation departmental talk, has significantly reduced the over-requesting of amylase and current practice is of a good standard. Improvements are still required. Resultantly, we are additionally producing an electronic ‘alert’ into our investigations software that, on requesting a repeat amylase, will prompt clinicians to consider its necessity. Other centres offering acute treatment for similar patients may benefit from performing a similar audit to optimise care while reducing overall clinical costs.

Low and high pancreatic amylase is associated with pancreatic cancer and chronic pancreatitis.

Incidences of pancreatic cancer and acute and chronic pancreatitis are rising globally, and often no curative treatment is available at the time of diagnosis. We tested the hypothesis that low and high plasma concentrations of pancreatic amylase are associated with increased risk of pancreatic cancer, acute pancreatitis, and chronic pancreatitis in the general population. We included 101,765 individuals (55% women) aged 20-100years from the Copenhagen General Population Study with baseline measurements of plasma pancreatic amylase. After recruitment in 2004-2015 during a median 9years of follow-up (range 0-15), we collected information about diagnoses of pancreatic cancer, acute pancreatitis, and chronic pancreatitis from the national Danish Patient Registry, the national Danish Cancer Registry, and the national Danish Causes of Death Registry. The median age was 58years (interquartile range: 48-67) and the median plasma pancreatic amylase 32 U/L (26-40). During follow-up, 442 individuals were diagnosed with pancreatic cancer, 282 with chronic pancreatitis, and 401 with acute pancreatitis. Compared to individuals with pancreatic amylase levels in the 41st-60th percentiles, those with extreme low (1st-2.5th percentiles) and extreme high (97.5th-100th percentiles) pancreatic amylase had hazard ratios of 2.4 (95% confidence interval; 1.6-3.6) and 2.2 (1.4-3.7) for pancreatic cancer, of 1.8 (1.1-3.3) and 3.2 (1.8-5.6) for chronic pancreatitis, and of 1.1 (0.6-1.8) and 1.5 (0.8-2.7) for acute pancreatitis, respectively. In apparently healthy individuals from the general population, extreme low and extreme high plasma pancreatic amylase were associated with 2-threefold higher risk of both pancreatic cancer and chronic pancreatitis.

Confirming diagnoses of acute pancreatitis with commonly available electronic data.

Recorded diagnoses of acute pancreatitis (AP) are often inaccurate resulting in limited utility for case identification in large data sources, especially where electronic medical records (EMR) are not available. Our objectives were to validate diagnoses of AP and to identify an algorithm using additional data to enhance the identification of AP cases in different data sources. We randomly sampled 550 persons with an AP diagnosis from inpatient data or outpatient or emergency department diagnoses immediately preceding a hospitalization and 150 negative controls with a differential diagnosis (cholangitis or cholecystitis). We conducted an EMR review to confirm cases of AP and used logistic regression to develop EMR-based and claims-based algorithms to identify confirmed AP cases with variables typically available in electronic data sources. Algorithm performance was assessed using the C statistic, sensitivity, specificity, and positive and negative predictive value. Of the 550 patients with an AP diagnosis, 467 (84.9%) were confirmed cases. An AP diagnosis alone had high sensitivity (98.9%), modest specificity (63.6%), and a C statistic of 0.813. An EMR-based model using an AP diagnosis, body mass index ≥30 kg/m2 , a serum lipase >3 times upper limit of normal and diabetes attained a C-statistic of 0.914. A claims-based model attained a C-statistic of 0.892 using an AP diagnosis and dichotomous variables for whether a serum lipase test and/or an abdominal ultrasound was performed. Our simple algorithms increased the accuracy of identification of AP cases providing widespread applicability to epidemiological and drug safety studies.

Genetic Variants Associated With Increased Plasma Levels of Triglycerides, via Effects on the Lipoprotein Lipase Pathway, Increase Risk of Acute Pancreatitis

Almost one third of adults in the West have increased plasma levels of triglycerides. Even mild to moderate hypertriglyceridemia (2-10 mmol/L or 177-886 mg/dL) is associated with an increased risk of acute pancreatitis. However, it is not clear whether hypertriglyceridemia is a cause or result of acute pancreatitis. Lipoprotein lipase degrades plasma triglycerides. Variants in LPL, APOA5, APOC3, ANGPTL3, and ANGPTL4, which regulate the lipoprotein lipase pathway, result in increased or reduced plasma triglyceride levels. We investigated associations between these variants and acute pancreatitis in a study of the general population. In a prospective cohort study, men and women randomly selected from the area of Copenhagen were invited to complete a questionnaire, undergo a physical examination, and provide blood samples for biochemical and genetic analyses, from 2003 through 2015. We obtained triglyceride measurements from 117,427 participants. We examined for 15 genetic variants that are associated with lipoprotein lipase function in DNA samples from 102,888 participants and analyzed data from 117,427 participants in observational analyses. Diagnoses of acute pancreatitis (970 diagnoses among participants in the genetic analysis and 527 among participants in the observational study) were obtained from Danish registries. We performed a 1-sample Mendelian randomization analysis in which specific variants were used as markers of the plasma level of triglycerides to determine the association between the plasma level of triglyceride and acute pancreatitis. We calculated unweighted, internally weighted, and externally weighted allele scores for each participant by adding numbers of triglyceride-increasing alleles. The highest genetic allele score correlated with a higher plasma level of triglycerides of 0.54 mmol/L (48 mg/dL). Among participants with the highest vs the lowest genetic allele score, the odds ratio for acute pancreatitis was 1.55 (95% CI, 1.08-2.23). Using instrumental variable analysis, integrating the effect of genotype on both triglycerides levels and risk of acute pancreatitis, we associated higher unweighted allele scores with an increased risk of acute pancreatitis (odds ratio [OR], 1.76; 95% CI, 1.16-2.65), as well as internally weighted higher allele scores (OR, 1.41; 95% CI, 1.01-1.97) and externally weighted higher allele scores (OR, 1.44; 95% CI, 1.01-2.04). Every 1 mmol/L (89 mg/dL) increase in triglycerides was observationally associated with an increase in OR of 1.09 (95% CI, 1.05-1.14) after multivariable adjustment. Based on an analysis of individuals with genetic variants associated with an increased level of triglycerides, via their effects on the lipoprotein lipase pathway, we associated an increased plasma levels of triglycerides with an increased risk of acute pancreatitis. Strategies to reduce plasma levels of triglycerides, by increasing lipoprotein lipase function, might be developed for prevention of acute pancreatitis.

2954 Acute Pancreatitis Outcomes May Not Be Worse in Subjects Post-Liver Transplant

INTRODUCTION: The association of Acute Pancreatitis and Celiac Disease (CD) has been sparingly reported in the literature. CD is known to affect approximately 1% of the western population. A Swedish national database study reported a 3-fold increased risk of developing pancreatitis in patients with CD. The exact mechanism of this is unknown, but it could be related to an untreated celiac disease affecting the major papilla causing stenosis or exocrine pancreatic insufficiency that has been reported previously. This study aimed to look at the association between acute pancreatitis and celiac disease. We also looked at whether there was any association between chronic pancreatitis and celiac disease. METHODS: We performed a retrospective cross-sectional cohort study using the 2013 National Inpatient Sample (NIS) database. We included all patients who were hospitalized with either acute pancreatitis (ICD Code 577.0) or Chronic Pancreatitis (577.1). Patients who had diagnoses of both acute and chronic pancreatitis were considered to have acute on chronic pancreatitis and combined with the chronic pancreatitis group. We then analyzed both groups for the presence or absence of celiac disease. Continuous variables were compared using t-tests, and categorical variables were compared using Rao-Scott chi-square tests. All analyses were performed using SAS Survey Procedures (version 9.4, The SAS Institute, Cary, NC). RESULTS: We analyzed more than 35 million hospitalizations in 2013 out of which 378,715 had a primary discharge diagnosis of acute pancreatitis and 155,130 had a primary discharge diagnosis of chronic pancreatitis. The mean age in the acute pancreatitis group was 53.3 yrs and in chronic pancreatitis group was 51.7 yrs. There were more males in chronic pancreatitis group (55.1%) than females (44.9%). There was significantly higher prevalence of acute pancreatitis in CD (2.3%) than non-CD patients (1.2%) (Figure 1, P = 0.001). Similarly, there was higher prevalence of chronic pancreatitis (1.2%) than the control group (0.43%) (Figure 1, P &lt; 0.001). CONCLUSION: There is a higher prevalence of acute pancreatitis in patients with CD. Patients were also found to have much higher prevalence of chronic pancreatitis in CD. This could be related to recurrent acute pancreatitis episodes in CD patients. Further studies are needed to validate these findings.

2915 Acute Pancreatitis and Celiac Disease—Is There an Association?

INTRODUCTION: The association of Acute Pancreatitis and Celiac Disease (CD) has been sparingly reported in the literature. CD is known to affect approximately 1% of the western population. A Swedish national database study reported a 3-fold increased risk of developing pancreatitis in patients with CD. The exact mechanism of this is unknown but it could be related to untreated celiac disease affecting the major papilla causing stenosis or exocrine pancreatic insufficiency that has been reported previously. The aim of this study was to look at the association between acute pancreatitis and celiac disease. We also looked whether there was any association between chronic pancreatitis and celiac disease. METHODS: We performed a retrospective cross-sectional cohort study using the 2013 National Inpatient Sample (NIS) database. We included all patients who were hospitalized with either acute pancreatitis (ICD Code 577.0) or Chronic Pancreatitis (577.1). Patients who had diagnoses of both acute and chronic pancreatitis were considered to have acute on chronic pancreatitis and combined with the chronic pancreatitis group. We then analyzed both groups for presence or absence of celiac disease. Continuous variables were compared using t-tests and categorical variables were compared using Rao-Scott chi-square tests. All analyses were performed using SAS Survey Procedures (version 9.4, The SAS Institute, Cary, NC). RESULTS: We analyzed more than 35 million hospitalizations in 2013 out of which 378,715 had a primary discharge diagnosis of acute pancreatitis and 155,130 had a primary discharge diagnosis of chronic pancreatitis. The mean age in the acute pancreatitis group was 53.3 yrs and in chronic pancreatitis group was 51.7 yrs. There were more males in chronic pancreatitis group (55.1%) than females (44.9%). There was significantly higher prevalence of acute pancreatitis in CD (2.3%) than non-CD patients (1.2%) (Figure 1, P = 0.001). Similarly, there was higher prevalence of chronic pancreatitis (1.2%) than the control group (0.43%) (Figure 1, P &lt; 0.001). CONCLUSION: There is a higher prevalence of acute pancreatitis in patients with CD. Patients were also found to have much higher prevalence of chronic pancreatitis in CD. This could be related to recurrent acute pancreatitis episodes in CD patients. Further studies are needed to validate these findings.

94 Necrotizing Pancreatitis Does Not Increase Odds of Mortality: Insights From a National Cohort

INTRODUCTION: Although most patients develop mild acute pancreatitis, some progress to necrotizing pancreatitis. Necrotizing pancreatitis has historically been associated with increased mortality as high as 30%. However, there are sparse studies reporting incidence of necrotizing pancreatitis from national cohort and its impact on patient related outcomes. Therefore, we aimed to analyze Necrotizing pancreatitis from a National cohort. METHODS: This was a retrospective study utilizing the 2016 National Inpatient Database Cohort for all principal discharges of acute pancreatitis in patients more than 18 years of age utilizing ICD 10 CM codes. Primary outcomes were incidence of necrotizing pancreatitis. Secondary outcomes were mortality, impact on healthcare utilization in terms of length of stay and hospitalization charges. These were then adjusted for confounders utilizing multivariate and Poisson regression analysis. All statistics were performed utilizing STATA software. RESULTS: Among total of 288,479 discharges with principal diagnoses of Acute Pancreatitis, 0.84% were necrotizing pancreatitis. Necrotizing pancreatitis significantly more frequent in young adults (49 years vs 51 years, P &lt; 0.0001) and male population (52.69% vs 69.83%, P &lt; 0.0001). As expected, presence of necrosis was associated with increased odds of complications such as Acute kidney injury and Acute respiratory distress syndrome. Approximately, 7% of the necrotizing pancreatitis cohort was associated with pancreatic resection. Acute necrotizing pancreatitis did not significantly increase the odds of mortality as shown in Table 2 after adjustment of confounders. Presence of necrosis was also associated with significantly longer length of stay in the hospital (4.31 days vs 12.10 days, P &lt; 0.0001) and significantly higher total hospitalization costs (9,264$ vs 29,948$, P &lt; 0.0001). CONCLUSION: Incidence of Acute necrotizing pancreatitis is approximately 8 per 1000 cases of acute pancreatitis. Even though, necrotizing pancreatitis led to significantly higher longer length of stay and hospitalization charges, mortality was not increased from necrotizing pancreatitis. No significant difference in mortality indirectly indicates aggressive IV fluid therapy, early recognition and resections when indicated. However, further studies are warranted to elucidate the reason explaining necrotizing pancreatitis in young and male population.

2980 Obesity Does Not Increase Risk of Mortality in Necrotizing Pancreatitis

INTRODUCTION: Obesity is considered an independent risk factor for increased severity of acute pancreatitis. However, the association of obesity with acute necrotizing pancreatitis and the impact on outcomes of necrotizing pancreatitis is sparsely described. Therefore, we aimed at impact of obesity on necrotizing pancreatitis in terms of inpatient mortality, length of stay and hospitalization charges. METHODS: This was a retrospective study utilizing the 2016 National Inpatient Database for all principal discharges of acute pancreatitis in obese patients more than 18 years of age utilizing ICD 10 codes. Primary outcomes were incidence of necrotizing pancreatitis in obese patients. Secondary outcomes were mortality, impact on healthcare utilization between the two cohorts. Multivariate analysis was utilized to adjust for confounders for evaluation of predictors of mortality. Poisson regression was performed for length of stay and hospitalization charges. RESULTS: Among total of 288,479 discharges with principal diagnoses of Acute Pancreatitis, 13.83% were associated with obesity. Acute necrotizing pancreatitis was associated with only 0.8% of the obese population with pancreatitis. There were no significant differences in terms of age, gender, ethnic differences in obese and normal BMI cohort. Acute kidney injury in necrotizing pancreatitis was more frequently observed in obese patients. There were no increased odds of mortality in obese patients with necrotizing pancreatitis as compared to patients with normal BMI after adjustment of confounders. Increasing age and male gender were significantly associated with increased odds of mortality in necrotizing patients. The length of stay was not significantly different in either of the cohorts (11.72 days vs 14.53 days). However, hospitalization charges were significantly higher in obese patients with necrotizing pancreatitis (27,867$ vs 44,113$, P 0.02). CONCLUSION: Even though obesity is an independent risk factor for severity of acute pancreatitis, incidence of obesity with necrosis was infrequent from a National Cohort. Acute kidney injury was more common in setting of obesity with necrosis which might explain the increased severity. However, obesity did not independently increase the odds of mortality in setting of necrotizing pancreatitis. Increasing age and male gender in setting of necrotizing pancreatitis leads to increased mortality. Further studies are warranted to elucidate the association of gender and necrotizing pancreatitis.

Frequency and risk factors for liver disease following pancreatitis: A population-based cohort study

Background & aimsBoth liver disease (LD) and pancreatitis pose substantial burdens. There have been no general population-based studies on frequency of LD after an episode of pancreatitis. The aim of this study was to investigate the occurrence of LD in a population-based cohort of patients following pancreatitis. MethodsNationwide data on the general population of nearly 3 million people were used to identify retrospectively diagnoses of acute pancreatitis, chronic pancreatitis (CP), LD and cirrhosis from 1998 to 2016. Acute pancreatitis was categorised as first (FAP) or recurrent (RAP) episode. Number of pancreatitis recurrences prior to LD diagnosis was determined. ResultsA total of 20,931 pancreatitis patients were included, of which 874 developed LD following pancreatitis. The incidence of LD in FAP was 115.59 (95% confidence interval 102.19–128.98), in RAP – 217.63 (95% confidence interval 173.31–261.94), and in CP – 539.43 (95% confidence interval 494.72–584.13) patients per 100,000 pancreatitis patients per year. There was a significant increase in the probability of LD with increasing number of pancreatitis recurrences and, for the same number of pancreatitis recurrences, LD was significantly more frequent after CP than RAP (hazard ratio 1.666 (95% confidence interval 1.322–2.098; p = <0.001)). ConclusionsThe frequency of LD increases from FAP to RAP to CP. While number of pancreatitis recurrences is a significant risk factor for development of LD, there is a higher probability of LD following CP than RAP even for the same number of recurrences. Interventions preventing pancreatitis and its progression may lower the burden of LD.

Positive predictive value of acute and chronic pancreatitis diagnoses in the Danish National Patient Registry: A validation study.

Aims: To examine the validity of the diagnoses of acute and chronic pancreatitis registered in the Danish National Patient Registry. Methods: We identified all patients in the Danish National Patient Registry admitted to two Danish hospitals with acute or chronic pancreatitis from 1996 to 2013. From this population, we randomly sampled 100 patients with acute pancreatitis and 100 patients with chronic pancreatitis. For each cohort, we computed the positive predictive values and associated 95% confidence intervals (CIs) for the discharge diagnosis of acute or chronic pancreatitis using medical records as the gold standard. Results: We identified 2617 patients with acute pancreatitis and 1284 patients with chronic pancreatitis discharged from either of the two hospitals during the study period. Of these, 776 (19.9%) had a diagnosis of both acute and chronic pancreatitis and are thus present in both cohorts. From the 200 sampled patients, a total of 138 (69.0%) medical records were available for review. The positive predictive value for a diagnosis of acute pancreatitis in the Danish National Patient Registry was 97.3% (95% CI 90.5-99.2%) and for chronic pancreatitis 83.1% (95% CI 72.2-90.3%). Conclusions: The validity of diagnoses of acute and chronic pancreatitis registered in the Danish National Patient Registry since 1996 is generally high.

Demographic profile of Acute Pancreatitis in Eastern India: A Single Centre Experience

Background: Little is known about the etiological risk factors of acute pancreatitis (AP) in Eastern India. Aims and Objective: The aim of this study is to assess current trends etiology of AP in Eastern India. Materials and Methods: A retrospective study with cross-sectional design was undertaken based on available medical records of patients admit between January 2014 and January 2017 with physician-assigned diagnoses of AP at KPC Medical College &amp; Hospital, Kolkata (n = 234). Multivariate analyses were done to identify risk factors, and distribution was compared on the basis gender. Groups were selected on the basis of a working diagnosis. A stratified comparison was done in 3 commonest etiology groups identified: ‘alcohol’, ‘non-alcohol’ and ‘idiopathic’.Results: The commonest etiology was attributed to alcohol (29.4%), idiopathic cause (20.5%), and obstructive cause (14.5%). Prevalence of AP was higher with alcoholism in men (37% vs. 10.8%; p &lt; 00.1), however, other causes like idiopathic cause (12.3% vs. 37.8%), duct obstruction (1.2% vs. 43.2%), obesity (6.1% vs. 24.3%), and hypertriglyceridemia (6.1% vs. 14.8%) were higher among females ( p &lt; 0.001 for all comparisons). Compared to non-alcoholics, patients with idiopathic AP were more likely to be overweight ( p = 0.019) and have T2 DM ( p = 0.021). Moreover, impact assessment of T2 DM status further revealed that the risk of AP was even greater with obesity (Odds Ratio [OR] 1.37; 95% Confidence Interval [CI] 0.57 – 3.26; p = 0.047) and smoking (OR 1.72; 95% CI 1.0 – 2.97; p = 0.049). Eighteen cases (7.7%) of ‘severe’ AP were identified, mostly due to: trauma in 6 (2.5%), idiopathic in 6 (2.5%), gallstones in 4 (1.7%), and alcoholism in 2 (0.8%).Conclusion: Alcohol intake is the predominant etiological risk factor for acute pancreatitis in Eastern India. Gender and type 2 diabetes mellitus are important contributory determinants.Asian Journal of Medical Sciences Vol.8(6) 2017 24-29

Inpatient Costs for Patients with Inflammatory Bowel Disease and Acute Pancreatitis

Introduction: Inflammatory bowel disease (IBD) is associated with an increased risk of acute pancreatitis. Hospitalizations for acute pancreatitis in patients with IBD are anticipated to be more economically complex. Our group examined differences in length of stay (LOS) and costs for patients with IBD hospitalized for acute pancreatitis and the general population. Methods: A retrospective study of the 2005-2011 National Inpatient Sample (NIS) was conducted. The NIS is the largest publicly available inpatient healthcare database in the US. The primary diagnoses of acute pancreatitis and co-diagnoses of IBD, ulcerative colitis (UC) and Crohn's disease (CD) were identified by ICD-9 codes. Continuous variables were reported as mean ± standard deviations and compared between IBD and controls by two-sample T-tests or Wilcoxon rank-sum tests, with normality assumptions based on the Shapiro-Wilk test. Categorical variables were analyzed by Chi-square tests or Fisher's exact tests. Propensity score matching method is widely used in observational studies to reduce selection bias. To fairly compare the outcomes of interest, we conducted 1:3 propensity score matching using a matching algorithm based on following: Age, gender, race, numbers of co-morbidities, procedure number, insurance, income quartiles, hospital bed size, hospital location, region and teaching status. Statistical analyses were performed on SAS 9.3 (Cary, NC), Windows platform. Results: There were a total of 4,291 hospitalizations of IBD patients with acute pancreatitis over the 7 year period and 379,627 hospitalizations of non-IBD patients with acute pancreatitis. The mean LOS of patients with acute pancreatitis and a co-diagnosis of IBD was 5.7 days versus 4.9 days for controls (p < 0.0001). Hospital costs were higher in patients with IBD compared to controls ($29,724.89 vs. $27,916.76 respectively, p < 0.0001). Survival rates were high in both groups, but slightly lower in patients with IBD (99.4% vs. 99.3% respectively). Higher LOS and costs were seen in patients with acute pancreatitis and a co-diagnosis of CD or UC (table 1). Rate of alcohol abuse was lower and drug abuse was higher in patients with a co-diagnosis of IBD (table 2). Conclusion: Our study suggests that cost and length of stay in patients with acute pancreatitis is influenced by a co-diagnosis of IBD. A co-diagnosis of CD or UC incurs a greater economic burden in patients with acute pancreatitis.Figure 1Figure 2

A prospective, claims‐based assessment of the risk of pancreatitis and pancreatic cancer with liraglutide compared to other antidiabetic drugs

AimWe evaluated the relationship between liraglutide and acute pancreatitis or pancreatic cancer in an ongoing post-marketing safety assessment programme.MethodsInitiators of liraglutide, exenatide, metformin, pioglitazone or groups containing initiators of dipeptidyl peptidase-4 inhibitors or sulfonylureas were identified in a US commercial health insurance claims database (1 February 2010 to 31 March 2013) and followed for a median of 15 months. We estimated incidence rates (IR/100 000 person-years), rate ratio (RR) and 95% confidence intervals (CI) of new insurance claims with diagnoses of primary inpatient acute pancreatitis or pancreatic cancer from Poisson regression models.ResultsThe IR for acute pancreatitis for liraglutide was 187.5 compared with 154.4 for all non-glucagon-like peptide-1 (GLP-1)-based therapies (adjusted RR 1.10; CI 0.81–1.49). The IR for pancreatic cancer was 19.9 for liraglutide compared with 33.0 for all non-GLP-1-based therapies (adjusted RR 0.65; 95% CI 0.26–1.60).ConclusionWe did not observe excess risk of either outcome associated with liraglutide relative to individual or pooled comparator drugs.

A pooled analysis of exenatide use and risk of acute pancreatitis

Objective:To estimate the association between exenatide BID use and acute pancreatitis across two claims-based studies.Research design and methods:We pooled two cohort studies within separate commercial health insurance databases. We included initiators of exenatide BID and all other antihyperglycemic drugs without prior pancreatitis from 2005−2008. Poisson regression models provided rate ratios (RRs) and 95% confidence intervals (CIs) of the association of exenatide BID with acute pancreatitis adjusted for quintiles of propensity scores.Main outcome measures:Primary inpatient diagnoses of acute pancreatitis with correction for misclassification via a validation sub-study.Results:There were 49,956 initiators of exenatide BID and 692,333 initiators of other antihyperglycemic drugs. Patients in the two studies were similar on many demographic and clinical characteristics. Exenatide BID initiators had a higher prevalence of diagnoses consistent with diabetes complications (e.g. peripheral neuropathy) and cardiovascular risk factors (e.g. hypertension). In both studies, current exenatide BID use was not associated with uncorrected outcomes of acute pancreatitis (pooled RR 1.0; CI 0.8–1.3). PPV correction resulted in a slightly higher point estimate for current use (pooled RR 1.3; CI 1.0–1.7) and past use (pooled RR 1.6; 95% CI 1.2−2.1).Conclusions:These data are consistent with little or no higher risk of acute pancreatitis associated with current exenatide BID use relative to nonuse. Although previous work identified non-causal mechanisms, an increased incidence of acute pancreatitis following cessation of treatment remains a possibility. Bias due to residual confounding or outcome misclassification may remain, and should be considered a potential explanation for these findings.

Microlithiasis of the gallbladder: role of endoscopic ultrasonography in patients with idiopathic acute pancreatitis

Causes may be found in most cases of acute pancreatitis, however no etiology is found by clinical, biological and imaging investigations in 30% of these cases. Our objective was to evaluate results from endoscopic ultrasonography (EUS) for diagnosis of gallbladder microlithiasis in patients with unexplained (idiopathic) acute pancreatitis. Thirty-six consecutive non-alcoholic patients with diagnoses of acute pancreatitis were studied over a five-year period. None of them showed signs of gallstones on transabdominal ultrasound or tomography. We performed EUS within one week of diagnosing acute pancreatitis. Diagnosis of gallbladder microlithiasis on EUS was based upon findings of hyperechoic signals of 0.5-3.0 mm, with or without acoustic shadowing. All patients (36 cases) underwent cholecystectomy, in accordance with indication from the attending physician or based upon EUS diagnosis. Twenty-seven patients (75%) had microlithiasis confirmed by histology and nine did not (25%). EUS findings were positive in twenty-five. Two patients had acute cholecystitis diagnosed at EUS that was confirmed by surgical and histological findings. In two patients, EUS showed cholesterolosis and pathological analysis disclosed stones not detected by EUS. EUS diagnosed microlithiasis in four cases not confirmed by surgical treatment. In our study, sensitivity, specificity and positive and negative predictive values to identify gallbladder microlithiasis (with 95% confidence interval) were 92.6% (74.2-98.7%), 55.6% (22.7-84.7%), 86.2% (67.4-95.5%) and 71.4% (30.3-94.9%), respectively. Overall EUS accuracy was 83.2%. EUS is a very reliable procedure to diagnose gallbladder microlithiasis and should be used for the management of patients with unexplained acute pancreatitis. This procedure should be part of advanced endoscopic evaluation.

This Month in Gastroenterology

This Month in Gastroenterology

Pancréatite aiguë et hyperparathyroïdie primaire : étude multicentrique de l’Association francophone de chirurgie endocrinienne

Primary hyperparathyroidism is an unusual cause of acute pancreatitis. The aim of this study was to analyse data from multiple centers concerning patients with primary hyperparathyroidism and associated acute pancreatitis and to analyze potential predictive factors.In this retrospective multicentric study, 19 patients were identified (Group A) with the associated diagnoses of acute pancreatitis and primary hyperparathyroidism. Their clinical data was compared to that of a control group of 65 patients (group B) with primary hyperparathyroidism without acute pancreatitis.Age, parathormone levels and pathology (uni/multiglandular disease) were similar between the two groups. The mean plasma calcium level was significantly higher in group A (12.64 mg/100ml) than in group B patients without pancreatitis (11.28 mg/100ml) (p<0.0001).This study confirms the causal relationship between primary hyperparathyroidism and acute pancreatitis. The degree of hypercalcemia may play an important role in this association. Calcium levels should be measured in all patients with acute pancreatitis.

Source Validation of Pancreatitis-Related Hospital Discharge Diagnoses Notified to a National Registry in The Netherlands

Background: National and regional disease registries are often used for epidemiological studies and validation analyses are scarce. We analyzed the reliability of the National Information System on Hospital Care (NISHC) registry used to classify admissions for acute and chronic pancreatitis in the Netherlands. Methods: All pancreas-related discharge diagnoses notified by the Academic Medical Center to the NISHC were retrieved for a 2-year time period. A review of multidis-ciplinary patient reports was conducted to verify these diagnoses. Results: 284 patients were notified to the NISHC, relating to 483 admissions with 523 pancreas-related discharge diagnoses. Of these diagnoses, 112 were coded as acute pancreatitis, 250 as chronic pancreatitis and 161 were classified as pseudocysts and other pancreatic diseases. The positive predictive value for acute pancreatitis diagnosis codes was 77.7% and 46 additional acute pancreatitis diagnoses were identified, ultimately leading to an underestimation of the total number of acute pancreatitis diagnoses of 15.8%. The positive predictive value for discharge diagnoses regarding chronic pancreatitis was 83.6% and 57 additional chronic pancreatitis diagnoses were identified, finally resulting in an underestimation of the total number of chronic pancreatitis diagnoses of 6%. Conclusion: There is a substantial miscoding on a person level of discharge diagnoses of acute and chronic pancreatitis. On a group level, when miscoding between categories is leveled out, actual numbers of admission are only slightly underestimated.