Diagnosis Of Gallstone Pancreatitis Research Articles

1268 An Audit of the Time to Surgery Following Diagnosis of Gallstone Pancreatitis

Abstract Aim To assess the compliance of our trust with the British Gastroenterology guidelines (BSG) on the management of gallstone pancreatitis which recommends that patients should undergo definitive treatment of laparoscopic cholecystectomy during the index admission or within 2 weeks of discharge to prevent readmission with biliary complications. Method This was a retrospective study of patients admitted with gallstone pancreatitis over a 3-month period between January 2021 and March 2021. We collected data from electronic medical records (EPR) and collated them on Microsoft Excel. Data was gathered on patient demographics, diagnosis at presentation, number of days to surgery, rate of readmission and the reasons for this. Results A total of 21 patients were admitted with gallstone pancreatitis. The median age was 50 years and 52% of them were male. 14 (67%) patients had laparoscopic cholecystectomy and only 9 (64%) of these had it within the 2-week window. 7 (33%) patients did not have surgery. Of these, 4 of them were not eligible, 1 went private and 2 patients are still awaiting surgery. The median wait for surgery was 3 days. The average time to surgery was 64 days. There were 6 readmissions whilst waiting for surgery with pain being the most common reason. Conclusions 64% of patients had definitive treatment of laparoscopic cholecystectomy within the 2-week time frame demonstrating poor compliance with the BSG guidelines. We have introduced a semi-emergency theatre list once a week to accommodate definitive management of patients with gallstone pancreatitis and will re-audit the data to evaluate for improvement.

Prediction of severe pancreatitis in a population with low atmospheric oxygen pressure

To establish the severity of pancreatitis, there are many scoring systems, the most used are the Marshall and APACHE II systems, each one has advantages and disadvantages; but with good relation regarding mortality and prediction of complications. In populations with low barometric pressures produced by a decrease in atmospheric pressure, there is a decrease in partial pressure of oxygen, in these cases scores which take arterial oxygen partial pressure as one of their variables, may be overestimated. A diagnostic trial study was designed to evaluate the performance of APACHE II, Marshall and BISAP in a city 2640 m above sea level. A ROC analysis was performed to estimate the AUC of each of the scores, to evaluate the performance in predicting unfavorable outcomes (defined as the need for percutaneous drainage, surgery, or mortality) and a non-parametric comparison was made between the AUC of each of the scores with the DeLong test. From January 2018 to December 2019, data from 424 patients living in Bogota, with a diagnosis of gallstone pancreatitis was collected consecutively in a hospital in Bogota, Colombia. The ROC analysis showed AUC for predicting adverse outcomes for APACHE II in 0.738 (95% CI 0.647–0.829), Marshall in 0.650 (95% CI 0.554–0.746), and BISAP in 0.744 (95% CI 0.654–0.835). The non-parametric comparison to assess whether there were differences between the different AUC of the different scores showed that there is a statistically significant difference between Marshall and BISAP AUC to predict unfavorable outcomes (p=0.032). The mortality in the group of patients studied was 5.8%. We suggest the use of BISAP to predict clinical outcomes in patients with a diagnosis of biliary pancreatitis in populations with decreased atmospheric pressure because it is an easy-to-use tool and does not require arterial oxygen partial pressure for its calculation.

S0043 Real World Practices of Same-admission Cholecystectomy in Gallstone Pancreatitis

INTRODUCTION: Cholecystectomy performed during an admission for gallstone pancreatitis (GP) has been reported to reduce both length of stay (LOS) and future encounters without causing an increase in complications. Despite this, rates of cholecystectomy remain low. To understand real-world trends of patients who underwent cholecystectomy after diagnosis of GP, we characterized their rates, risks, benefits, comorbid conditions, location of care and contrasted them across a nine-hospital system. METHODS: ICD-10 codes were used to retrieve charts of patients presenting to the MedStar Health between March 2015 and June 2019. These included emergency department visits and inpatient admissions. Charts meeting Revised Atlanta Classification for acute pancreatitis (AP) were reviewed. Charts that carried a diagnosis of GP were put into two groups, 1) those that underwent same-admission cholecystectomy (SAC) and 2) those who did not. These groups were then compared for the following variables: LOS, future encounter and complication rates, location of care, history of cholelithiasis or choledocholithiasis and presence of hypertension, coronary artery disease, congestive heart failure, asthma/chronic obstructive pulmonary disease, smoking status, chronic kidney disease or cirrhosis. Statistical analysis was performed using GraphPad PRISM. RESULTS: 1722 of 2541 charts met criteria for AP; 366 of which carried a diagnosis of GP. LOS was observed to be greater in those who underwent SAC when compared to those who did not (5.5 vs 4.2 days, 95% Cl 0.26–2.26, P = 0.0138.) Patients at tertiary centers were observed to have been less likely to undergo SAC (31.4% vs 44.5%, OR 0.570, P = 0.0151.) There was no significant difference in rates of future encounters or complications, presence of comorbidities or history of either cholelithiasis (50.0% vs 48.4%, P = 0.831) or choledocholithiasis (7.64% vs 8.60%, P = 0.847) between the two groups. CONCLUSION: In patients with GP, SAC was associated with increased LOS. Despite the association between choledocholithiasis or cholelithiasis and GP, there was no correlation between SAC and history of these prior conditions. This lower rate of SAC at tertiary centers could reflect a lack of penetrance of guideline adherence. Given these findings, the balance between benefit and risk remains to be one that warrants careful consideration and further investigation.Figure 1.: Length of stay compared between same-admission cholecystectomy and no cholecystectomy groupsFigure 2.: Prevalence of cholelithiasis history in same-admission cholecystectomy and no cholecystectomy groups.Figure 3.: Prevalence of choledocholithiasis history in same-admission cholecystectomy and no cholecystectomy groups.

S3086 Predicting Gallstone Pancreatitis: A Pilot Study

INTRODUCTION: Acute pancreatitis, a life-threatening disease with increasing incidence worldwide, is the most common gastrointestinal cause of hospitalization in the United States. Gallstone Pancreatitis (GP) makes up for about 40%-70% of cases. Distinguishing GP from other causes is of clinical importance as it can change the management, primarily whether the patient should undergo cholecystectomy. METHODS: This retrospective, cross-sectional chart review examined patients ≥18 years old with a diagnosis of pancreatitis at a single hospital in South Texas between September 2014 and December 2019. Cases were included if two of three criteria were met: 1) acute abdominal pain; 2) serum lipase ≥3 times the upper limit of normal (920 units/L); and/or 3) findings of acute pancreatitis on CT scan. Patients with post-ERCP pancreatitis were excluded from analyses. Differences in descriptive statistics between GP and non-GP were evaluated using t-test and chi-square. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for the diagnosis of GP were calculated separately for ALT, AST, lipase, alkaline phosphatase (AP) and total bilirubin (T Bili). Statistical analyses were conducted using R version 4.0.0. RESULTS: After chart-review, 405 patients met the inclusion criteria for this study. We found that 37.8% had a diagnosis of GP. The mean age of included patients was 53.1 years (SD = 18.8). No significant difference in Body Mass Index was found between GP and non-GP (GP: 31.5 vs non-GP: 30.7, P = 0.325). The Female:Male ratio was significantly higher in GP than non-GP (GP: 1.83 vs non-GP: 1.1, P = 0.020). AST, ALT, lipase, AP, and T Bili were also significantly higher in GP than non-GP (Table 1). The PPV for ALT >150 units/L to diagnose GP was 88% (range: 81-93). AST, lipase, AP, and T Bili findings are shown in Table 2 and Figure 1. CONCLUSION: The majority of cases were attributed to GP. Moreover, in 35.5% of the cases, the underlying etiology was not identified. In patients with acute pancreatitis we determined that ALT >150 units/L has a PPV of 88% of diagnosing GP. Lipase, AP, AST and T Bili did not show the same potential as a single laboratory value; however, they were all significantly higher in GP compared to non-GP. Further research combining laboratory values and risk factors would help pave the way to the creation of a predictive scoring system for GP, thus decreasing unnecessary studies and diagnoses of ‘idiopathic’ acute pancreatitis.Table 1.: Descriptive StatisticsTable 2.: Sensitivity, Specificity, PPV and NPV for Diagnosing Gallstone PancreatitisFigure 1.: Laboratory Values ROC Curves.

Acute care surgery: a means for providing cost-effective, quality care for gallstone pancreatitis

BackgroundModern practice guidelines recommend index cholecystectomy (IC) for patients admitted with gallstone pancreatitis (GSP). However, this benchmark has been difficult to widely achieve. Previous work has demonstrated that dedicated acute care surgery (ACS) services can facilitate IC. However, the associated financial costs and economic effectiveness of this intervention are unknown and represent potential barriers to ACS adoption. We investigated the impact of an ACS service at two hospitals before and after implementation on cost effectiveness, patient quality-adjusted life years (QALY) and impact on rates of IC.MethodsAll patients admitted with non-severe GSP to two tertiary care teaching hospitals from January 2008–May 2015 were reviewed. The diagnosis of GSP was confirmed upon review of clinical, biochemical and radiographic criteria. Patients were divided into three time periods based on the presence of ACS (none, at one hospital, at both hospitals). Data were collected regarding demographics, cholecystectomy timing, resource utilization, and associated costs. QALY analyses were performed and incremental cost effectiveness ratios were calculated comparing pre-ACS to post-ACS periods.ResultsIn 435 patients admitted for GSP, IC increased from 16 to 76% after implementing an ACS service at both hospitals. There was a significant reduction in admissions and emergency room visits for GSP after introduction of ACS services (p < 0.001). There was no difference in length of stay or conversion to an open operation. The implementation of the ACS service was associated with a decrease in cost of $1162 per patient undergoing cholecystectomy, representing a 12.6% savings.The time period with both hospitals having established ACS services resulted in a highly favorable cost to quality-adjusted life year ratio (QALY gained and financial costs decreased).ConclusionsACS services facilitate cost-effective management of GSP. The result is improved and timelier patient care with decreased healthcare costs. Hospitals without a dedicated ACS service should strongly consider adopting this model of care.

32-Year-Old-Woman With Abdominal Pain

32-Year-Old-Woman With Abdominal Pain

Early cholecystectomy in children with gallstone pancreatitis reduces readmissions

BackgroundMultiple guidelines exist in adult practice regarding the timing of cholecystectomy for gallstone pancreatitis. Current evidence to support their application to pediatric practice is minimal. This study sought to determine the effect of timing of cholecystectomy for gallstone pancreatitis in children on the risk of readmission. MethodAll patients younger than 19years of age presenting to an acute NHS trust in England with a diagnosis of gallstone pancreatitis between 1 January 1999 and 31st December 2009 were included. Patient level data were extracted from the English Hospital Episode Statistic Database. ICD10, OPCS4.6 and hospital administrative data were used to determine: diagnosis, age, associated comorbidities and subsequent procedures performed. Results670 cases of gallstone related pancreatitis were recorded in younger than 19years old between 1999 and 2009 resulting in 3 deaths during this period. The majority (534/670) underwent a cholecystectomy which was performed less than two weeks from primary admission in 33% (174/534) of cases. Cholecystectomy within two weeks provides an actual risk reduction (ARR) of readmission of 57.5% (95% CI 50.1 to 64.4%, p<0.0001, NNT 2). No significant difference was identified in operative complications or mortality following early cholecystectomy in this group (p>0.05). ConclusionsReadmissions can be significantly reduced in this population by performing a cholecystectomy within two weeks with no apparent rise in surgical complications.

Radionuclide Biliary Scanning in the Diagnosis of Gallstone Pancreatitis

The ability of hepatobiliary scanning (99mTc HID A) to distinguish gallstone (GS) from non-gallstone (NGS) pancreatitis was investigated in 29 patients. 4 patients had repeat scans during a

Diagnostic Imaging Procedures in Acute Pancreatitis

To evaluate the role of intravenous cholangiography (IVC), ultrasound andoral cholecystography in the diagnosis of gallstone pancreatitis, 20 patients with acute pancreatitis were studied during the first three days of an attack. The IVC successfully demonstrated the common bile duct and gallbladder in 17 (85%) 20 patients. The ultrasound studies showed the gallbladder in all 18 patients in whom the gallbladder was present. The common duct was not seen by ultrasound in any patient and the pancreas was abnormal in all patients. In the three patients with gallbladder stones these were identified on both IVC and ultrasound. Common duct stones in three patients were seen only by IVC (two of these patients had concurrent gallbladder stones and one after cholecystectomy). Oral cholecystography was of limited usefulness, although the 50% visualization rate was higher than the literature suggests.

Diagnostic imaging procedures in acute pancreatitis. Comparison of ultrasound, intravenous cholangiography, and oral cholecystography

To evaluate the role of intravenous cholangiography (IVC), ultrasound and oral cholecystography in the diagnosis of gallstone pancreatitis, 20 patients with acute pancreatitis were studied during the first three days of an attack. The IVC successfully demonstrated the common bile duct and gallbladder in 17 (85%) of 20 patients. The ultrasound studies showed the gallbladder in all 18 patients in whom the gallbladder was present. The common duct was not seen by ultrasound in any patient and the pancreas was abnormal in all patients. In the three patients with gallbladder stones these were identified on both IVC and ultrasound. Common duct stones in three patients were seen only by IVC (two of these patients had concurrent gallbladder stones and one after cholecystectomy). Oral cholecystography was of limited usefulness, although the 50% visualization rate was higher than the literature suggests. (<i>JAMA</i>242:342-343, 1979)