Revised Atlanta Classification Research Articles

Diagnostic Accuracy of Bedside Index for Severity in Acute Pancreatitis and Modified Computed Tomography Severity Index in Determining the Severity of Acute Pancreatitis using Revised Atlanta Classification as the Gold Standard

Objective: To determine the diagnostic accuracy of modified computed tomography severity index (CTSI) and Bedside index for severity in acute pancreatitis (BISAP) scoring system in predicting severity in acute pancreatitis, keeping the Revised Atlanta Classification (RAC) as the gold standard.
 Study Design: Prospective longitudinal study.
 Place and Duration of Study: Department of Gastroenterology, Pak Emirates Military Hospital, Rawalpindi Pakistan, Pakistan from Jan to Jul 2022.
 Methodology: This study was conducted on 100 patients with acute pancreatitis, both genders and ages. Patients with chronic pancreatitis, pancreatic calcifications, dilated pancreatic duct, areas of atrophy and pseudocysts were excluded. Detailed history and physical examination, and laboratory investigations were performed. Modified CTSI, BISAP and RAC were calculated. RAC was used as the gold standard. Sensitivity, specificity and other diagnostic parameters were calculated using R programme.
 Results: The mean age was 42.42±18.07 years. The males were 53%, and the females were 47%. CTSI was sensitive at 100%, specific at 58.43%, and overall diagnostic accuracy at 63%. BISAP was sensitive at 100%, specific at 68.54%, and overall diagnostic accuracy at 72%. 
 Conclusion: BISAP and modified CTSI can assess severe acute pancreatitis (SAP) at primary and secondary care levels, enabling early triage and referral to higher centers.

Cutoff Value of Psoas Muscle Area as Reduced Muscle Mass and Its Association with Acute Pancreatitis in China.

The Global Leadership Initiative on Malnutrition (GLIM) has proposed criteria for the diagnosis of malnutrition, one of which is reduced muscle mass. Computed tomography (CT) assessment of psoas muscle area (PMA) has been used to estimate muscle mass in patients, including those with acute pancreatitis (AP). The present study aimed to define the cutoff value of PMA indicative of reduced muscle mass in patients with AP and to assess the impact of reduced muscle mass on the severity and early complications of AP. Clinical data of 269 patients with AP were analyzed retrospectively. The severity of AP was determined according to the revised Atlanta classification. PMA was evaluated by CT and used to calculate the psoas muscle index (PMI). Cutoff values for reduced muscle mass were calculated and validated. Logistic regression analysis was performed to assess the relationship between PMA and the severity of AP. PMA was a better indicator of reduced muscle mass than PMI, with cutoff values of 11.50 cm2 for men and 8.22 cm2 for women. Rates of local complications, splenic vein thrombosis, and organ failure were significantly higher in AP patients with low than high PMA (all p < 0.05). PMA showed good ability to predict splenic vein thrombosis in women, with an area under the receiver operating characteristic curve of 0.848 (95% confidence interval 0.768-0.909, sensitivity 100%, specificity 83.64%). Multivariate logistic regression revealed that PMA was an independent risk factor for moderately severe plus severe AP (odds ratio 5.639, p = 0.001) and severe AP (odds ratio 3.995, p = 0.038). PMA is a good predictor of the severity and complications of AP. The PMA cutoff value is a good indicator of reduced muscle mass.

Current trends in acute pancreatitis: Diagnostic and therapeutic challenges.

Acute pancreatitis (AP) is an inflammatory disease of the pancreas, which can progress to severe AP, with a high risk of death. It is one of the most complicated and clinically challenging of all disorders affecting the abdomen. The main causes of AP are gallstone migration and alcohol abuse. Other causes are uncommon, controversial and insufficiently explained. The disease is primarily characterized by inappropriate activation of trypsinogen, infiltration of inflammatory cells, and destruction of secretory cells. According to the revised Atlanta classification, severity of the disease is categorized into three levels: Mild, moderately severe and severe, depending upon organ failure and local as well as systemic complications. Various methods have been used for predicting the severity of AP and its outcome, such as clinical evaluation, imaging evaluation and testing of various biochemical markers. However, AP is a very complex disease and despite the fact that there are of several clinical, biochemical and imaging criteria for assessment of severity of AP, it is not an easy task to predict its subsequent course. Therefore, there are existing controversies regarding diagnostic and therapeutic modalities, their effectiveness and complications in the treatment of AP. The main reason being the fact, that the pathophysiologic mechanisms of AP have not been fully elucidated and need to be studied further. In this editorial article, we discuss the efficacy of the existing diagnostic and therapeutic modalities, complications and treatment failure in the management of AP.

Predictive value of serum apolipoprotein A-I in the organ failure of acute pancreatitis: a retrospective cohort study

Background Organ failure (OF) largely governs the outcomes and mortality in patients with acute pancreatitis (AP), but there is a lack of optimal prognostic biomarker for OF. This study is designed to investigate whether the serum apolipoprotein A-I (Apo A-I) level can predict OF in patients with AP. Methods A total of 424 patients with AP were reviewed in the study, and we finally got 228 patients eligible for analysis. Patients were divided into two groups based on serum Apo A-I level. Demographic information and clinical materials were retrospectively collected. The primary outcome was the occurrence of OF. Univariate and multivariate binary logistic regression were conducted to analyze the relationship between Apo A-I and OF. Additionally, we used receiver operating characteristic analysis to clarify the predictive value of serum Apo A-I level for OF and mortality. Results Ninety-two patients and 136 patients were included in Apo A-I low and non-low groups, respectively. The occurrence of OF was significantly different in the two groups (35.9 vs. 9.6%, p < 0.001). Moreover, serum Apo A-I level markedly decreased across disease severity based on the 2012 Revised Atlanta Classification of AP. The decrease of serum apolipoprotein A-I was an independent risk factor for organ failure (OR: 6.216, 95% CI: 2.610, 14.806, p < 0.001). The area under the curve of serum Apo A-I was 0.828 and 0.889 for OF and mortality of AP, respectively. Conclusions Serum Apo A-I level in the early stage of the disease has a high predictive value for OF of AP.

Early vs. late percutaneous catheter drainage of acute necrotic collections in patients with necrotizing pancreatitis.

It is recommended to drain the pancreatic fluid collections later in the course of the acute necrotizing pancreatitis (ANP). However, earlier drainage may be indicated. We compared early (≤ 2weeks) vs. late (3rd to 4th week) percutaneous catheter drainage (PCD) of acute necrotic collections (ANC). This retrospective study comprised ANP patients who underwent PCD of ANC. The diagnosis of ANP was based on revised Atlanta classification criteria and computed tomography performed between 5 and 7days of illness. Patients were divided into two groups [1st 2 weeks (group I) and 3rd-4th weeks (group II)] based on the interval between the onset of pain and insertion of catheter. The technical success, clinical success, complications, and clinical outcomes were compared between the two groups. One hundred forty-eight patients (74 in each group) were evaluated. The procedures were technically successful in all patients. The clinical success rate was 67.6% in group I vs. 77% in group II (p = 0.069). The incidence of complications was significantly higher in group I (n = 12, 16%) than group II (n = 4, 5.4%) (p = 0.034). These included 15 minor (11 in group I and 4 in group II) and one major complication (group I). Of the clinical outcomes, the need for surgery was significantly higher in group I than in group II (13 patients vs. 5 patients, p = 0.031). Early PCD is as technically successful as late PCD in the management of ANC. However, early PCD is associated with higher surgical rate and higher incidence of complications.

Metabolic-associated fatty liver disease is associated with acute pancreatitis with more severe course: Post hoc analysis of a prospectively collected international registry.

Non-alcoholic fatty liver disease (NAFLD) is a proven risk factor foracute pancreatitis (AP). However, NAFLD has recently been redefined as metabolic-associated fatty liver disease (MAFLD). In this post hoc analysis, we quantified the effect of MAFLD on the outcomes of AP. We identified our patients from the multicentric, prospective International Acute Pancreatitis Registry of the Hungarian Pancreatic Study Group. Next, we compared AP patients with and without MAFLD and the individual components of MAFLD regarding in-hospital mortality and AP severity based on the revised Atlanta classification. Lastly, we calculated odds ratios (ORs) with 95% confidence intervals (CIs) using multivariate logistic regression analysis. MAFLD had a high prevalence in AP, 39% (801/2053). MAFLD increased the odds of moderate-to-severe AP (OR=1.43, CI: 1.09-1.89). However, the odds of in-hospital mortality (OR=0.89, CI: 0.42-1.89) and severe AP (OR=1.70, CI: 0.97-3.01) were not higher in the MAFLD group. Out of the three diagnostic criteria of MAFLD, the highest odds of severe AP was in the group based on metabolic risk abnormalities (OR=2.68, CI: 1.39-5.09). In addition, the presence of one, two, and three diagnostic criteria dose-dependently increased the odds of moderate-to-severe AP (OR=1.23, CI: 0.88-1.70, OR=1.38, CI: 0.93-2.04, and OR=3.04, CI: 1.63-5.70, respectively) and severe AP (OR=1.13, CI: 0.54-2.27, OR=2.08, CI: 0.97-4.35, and OR=4.76, CI: 1.50-15.4, respectively). Furthermore, in patients with alcohol abuse and aged ≥60years, the effect of MAFLD became insignificant. MAFLD is associated with AP severity, which varies based on the components of its diagnostic criteria. Furthermore, MAFLD shows a dose-dependent effect on the outcomes of AP.

Presentation of Acute Pancreatitis in Sickle Cell Disease Patients: A Single Hospital Experience.

Sickle cell disease (SCD) is a haemoglobinopathy that leads to the formation of distorted sickle-shaped red blood cells that are prone to vaso-occlusion. This may lead to vaso-occlusive crises that may affect any organ. Acute pancreatitis (AP) in SCD patients may be mimicked by a vaso-occlusive crisis in the abdomen. The objective of this article is to analyse the clinical profiles of SCD patients with AP and understand the differences in the presentation of AP compared to an abdominal vaso-occlusive crisis and the difference between its presentation in SCD patients in comparison to other patients. Twenty-eight SCD patients who were diagnosed with AP during their admission to the paediatric department at a tertiary hospital between January 2012 and December 2020 were retrospectively studied. Patients aged older than 14 years were excluded. The data collected concerned: demographics, the clinical course and the hospital course. The diagnosis and severity protocols followed the revised Atlanta Criteria. The patients were aged with a mean of 9.61 years. There were 15 males and 13 females. Demographics were not significantly correlated to complication rates (P > 0.05). The mean duration of hospitalisation was 6.43 days. The most common clinical presentations were abdominal pain, fever, then vomiting and nausea. Three patients experienced complications and they were all cases of cholangitis (10.71%). There were no cases of pseudocysts, acute necrotic collections, pancreatic or peripancreatic necrosis or walled-off necroses. All of the cases of AP in SCD children were mild according to the revised Atlanta classification. Leucocytosis was present in 29.29% of patients and 17.8% of patients had high C-reactive proteins (CRPs). There was no significant correlation between leucocyte counts, CRP levels, serum or urinary amylase levels and complications (P > 0.05). All patients had haemoglobin (Hb) levels above 7 g/dL. The levels of sickle Hb ranged from 40 to 70 g/dL and reticulocyte counts averaged at 3.57%. Haematologic parameters were not significantly correlated with complication rates (P > 0.05). There were no recurrences. AP in SCD patients presented with classic signs and symptoms. There were no associations between demographics and complications. The levels of leucocytes, CRP counts and serum and urinary amylase were not correlated with complications. The level of Hb and sickle cell Hb was not associated with complication rates. Reticulocytes were slightly elevated in SCD patients with AP. More studies are needed to demarcate factors distinguishing AP in SCD from abdominal vaso-occlusive crises.

EVALUATION OF PROGNOSTIC SIGNIFICANCE OF CRP, IONIC CALCIUM,AND SERUM ALBUMIN IN ACUTE PANCREATITIS

Introduction: Acute pancreatitis is defined as an inflammatory process of pancreas with possible peripancreatic tissue involvement and multi organ dysfunction syndrome with increasing mortality rate. In response to initial insult, acinar cells release proinflammatory cytokines, such as TNF a, IL-1, 2 and 6, and anti-inflammatory mediators such as IL-10 and IL-1 receptor antagonist. Acute pancreatitis is best diagnosed clinically in a patient presenting with 2 of the 3 following criteria.(1) Symptoms consistent with pancreatitis,(2) Serum lipase or amylase levels more than 3 times the laboratorys upper range of normal, and (3) Radiologic features suggestive of pancreatitis, usually using CECT. Usually, the first two criteria are present, and CECT is not required for diagnosis. Aims &amp; Objective: 1. To determine the prognosis of acute pancreatitis on the basis of quantitative value of CRP,SERUM ALBUMIN AND IONIC CALCIUM in admitted patients of HIMS on day of admission and after 48hours.2. To assess the severity of acute pancreatitis as mild,moderate,severe form(as per REVISED ATLANTA CLASSIFICATION 2013) and compare it with values of CRP,SERUM ALBUMIN AND IONIC CALCIUM. Methodology: The study will be conducted over a period of 18months (January 2021 to July 2022) in which all patients coming to General Surgery department at Hind Institute of Medical Sciences, Barabanki, UP with diagnosis of acute pancreatitis will be included. Result: We found that male population was higher than the female population. which was statistically significant. Higher number of patients had Pain in Abdomen Since 3 Days and patients were Alcoholic but this was statistically significant.Association of CRP Value with Day is statistically significant.Association of serum albumin value with Day is statistically significant. Association of Ionic Calcium value with Dayis statistically significant. This study shows that there is relation between se.CRP,se.Albumin and ionic calcium to assess the severity of Acute Pancreatitis.

Imaging Features of Acute Pancreatitis and the Revised Atlanta Classification System

Contemporary Diagnostic Radiology 46(2):p 8, January 15, 2023. | DOI: 10.1097/01.CDR.0000905608.54137.e2

Imaging Features of Acute Pancreatitis and the Revised Atlanta Classification System

Acute pancreatitis is a major cause of hospital admissions in the United States, with the two primary causes being gallstones and alcohol.1 The Atlanta classification system is an international classification on the severity of acute pancreatitis. In 2012, deficiencies and outdated nomenclature were removed to make a revised system that take into account advancements in research and clinical management. The revised Atlanta classification system (RACS) in 2012 standardized the nomenclature for acute pancreatitis and local complications to facilitate effective communication between clinicians and radiologists alike. Older terms such as pancreatic abscess, phlegmon, acute pseudocyst, and fluid collection are no longer used, as they are vague and can be misleading.

Anemia can predict organ failure in acute pancreatitis.

Acute pancreatitis (AP) is the leading hospital admission in Gastroenterology and has a variable clinical course. Identifying severity of AP patients in its early stages is of foremost importance to improve prognosis. The revised Atlanta Classification grades AP severity by the presence of organ failure and local complications.

Red Cell Distribution Width and Ratio of Red Cell Distribution Width-to-Total Serum Calcium as Predictors of Outcome of Acute Pancreatitis.

Current severity assessment scores of acute pancreatitis (AP) include multiple variables, the results of which are available only after 48 h of admission. Red cell distribution width (RDW) and total serum calcium (TSC) are simple routine parameters related to inflammatory status and results of which are readily available. The aim of this study was to evaluate RDW and RDW: TSC within 24 h of hospital admission as predictors of outcome (severity and mortality) and intervention (medical/percutaneous drainage/surgical) required by patients of AP. All the patients diagnosed with AP at a tertiary care hospital were enrolled for the study. Values of RDW and TSC along with data regarding the treatment given were collected. Diagnosis and severity were defined according to the revised Atlanta classification 2012. Cutoff value for RDW (area under the receiver operating characteristic curve [AUROC]: 0.997; P = 0.000) to predict the severity of AP was 16.25% (sensitivity - 100% and specificity - 97.1%,) (sensitivity - 100% and specificity - 97.1%, positive predictive value - 92.31%, negative predictive value - 100%, and Youden Index - 0.971), while that of RDW:TSC (AUROC: 1; P = 0.000) was 2.42 (sensitivity - 100%; specificity - 100%, positive predictive value - 100%, negative predictive value - 100%, and Youden Index - 1.00). Similarly, the cutoff value for RDW (AUROC: 0.947; P = 0.000) to predict mortality in AP was 17.20% (sensitivity - 100%; specificity - 87.4%, positive predictive value - 38.89%, negative predictive value - 100%, and Youden Index - 0.874) and that of RDW-to-TSC ratio (AUROC: 0.975; P = 0.000) was 2.9 (sensitivity - 100%; specificity - 96.6%, positive predictive value - 70%, negative predictive value - 100%, and Youden Index - 0.966). Our study found that RDW and RDW: TSC were quick, convenient, economic, sensitive, and dependable prognostic predictors of severity and mortality in patients with AP.

Assessment of Severity of Pancreatitis by Computerized Tomography Using Revised Atlanta Classification and Comparison with BISAP Clinical Scoring System

Abstract Background: Untreated acute pancreatitis can have high morbidity and mortality. It is a serious gastrointestinal emergency. Its incidence is approximately 51.0 % and it can cause both local and systemic problems. The diagnosis usually involves laboratory tests like amylase and lipase as well as an ultrasound exam. The ideal imaging test is a contrast-enhanced CT scan. This study used scoring systems based on laboratory and radiological investigations to determine the clinical progression and outcome. Methods : Patients who were diagnosed with acute pancreatitis and in whom computed tomography was done were included. From the imaging findings, the category and subcategory of acute pancreatitis and types of fluid collections were described in these patients using the revised Atlanta classification. BISAP score was calculated in all these patients. The clinical outcome assessed in these patients is the duration of stay in the hospital, mortality, presence of persistent organ failure, the occurrence of infection and need for intervention. Finally, the correlation between the Revised Atlanta classification and BISAP score was analyzed and compared with clinical outcomes. Results: The analysis of the correlation between Revised Atlanta classification severity grade and BISAP score, among the n=57 patients with mild acute pancreatitis n=56, had BISAP score less than 3 and only one had BISAP score greater or equal to three. Among the n=25 patients graded as moderately severe acute pancreatitis, n=20 cases had a BISAP score of less than 3 and n=5 had BISAP score greater than or equal to three. Among the n=08 patients graded as severe acute pancreatitis, n=3 had a BISAP score of less than 3 and n=5 had BISAP score greater than or equal to three. Conclusion: Standardizing nomenclature and facilitating proper documentation of a variety of imaging abnormalities in acute pancreatitis is made possible by incorporating the new Atlanta categorization system into daily practice. We can triage, predict, and treat patients with acute pancreatitis with greater precision by integrating the new Atlanta classification with BISAP clinical grading, significantly improving medical care.

Early prediction of the severe course, survival, and ICU requirements in acute pancreatitis by artificial intelligence

ObjectiveTo evaluate the success of artificial intelligence for early prediction of severe course, survival, and intensive care unit(ICU) requirement in patients with acute pancreatitis(AP). MethodsRetrospectively, 1334 patients were included the study. Severity is determined according to the Revised Atlanta Classification(RAC). The success of machine learning(ML) method was evaluated by 13 simple demographic, clinical, etiologic, and laboratory features obtained on ER admission. Additionally, it was evaluated whether Balthazar-computerized tomography severity index(CTSI) at 48-h contributed to success. The dataset was split into two parts, 90% for ML(of which 70% for learning and 30% for testing) and 10% for validation and 5-fold stratified sampling has been utilized. Variable Importance was used in the selection of features during training phase of machine. The Gradient Boost Algorithm trained the machine by KNIME analytics platform. SMOTE has been applied to increase the minority classes for training. The combined effects of the measured features were examined by multivariate logistic regression analysis and reciever operating curve curves of the prediction and confidence of the target variables were obtained. ResultsAccuracy values for the early estimation of Atlanta severity score, ICU requirement, and survival were found as 88.20%, 98.25%, and 92.77% respectively. When Balthazar-CTSI score is used, results were found as 91.02%, 92.25%, and 98% respectively. ConclusionsThe ML method we used successfully predicted the severe course, ICU requirement and survival, with promising accuracy values of over 88%. If 48-h Balthazar-CTSI is included in the calculation, the severity score and survival rates increase even more.

Supportive treatment during the periprocedural period of endoscopic treatment for pancreatic fluid collections: a critical review of current knowledge and future perspectives.

Pancreatic fluid collections (PFCs) commonly develop as complications of acute pancreatitis and ductal disruption due to chronic pancreatitis. In the revised Atlanta classification, PFCs were classified based on the presence of necrosis and duration following the onset of acute pancreatitis. Interventions are required in cases of symptomatic pancreatic pseudocysts or walled-off necrosis (WON). In the management of these PFCs, endoscopic ultrasound-guided transluminal drainage and subsequent direct endoscopic necrosectomy for WON are increasingly utilized as less invasive treatment modalities compared to surgical debridement. To date, researchers have focused predominantly on the technical aspects of endoscopic therapy for symptomatic PFCs. Given the poor physical condition of patients receiving endoscopic treatment for PFCs, systemic support may have a substantial impact on the short- and long-term outcomes of these patients. A multidisciplinary approach is required to improve the clinical outcomes of patients with infected PFCs and their associated comorbidities. However, non-interventional support during the periprocedural period of endoscopic treatment of PFCs has not been fully discussed, and there have been considerable variations in the selection of treatment options between endoscopists and centers. To address these unmet needs in the clinical management of PFCs and promote future research to improve the clinical outcomes, we conducted a review of the literature within a multicenter consortium of expert endoscopists with specific expertise in the endoscopic treatment of PFCs. In this review, we summarize the current evidence on non-interventional supportive care (e.g., continuous lavage, medications, nutritional support, and antimicrobials) and propose potential topics for future research.

Imaging of Acute Pancreatitis According to the Revised Atlanta Classification

Imaging of Acute Pancreatitis According to the Revised Atlanta Classification

Early versus delayed interventions for necrotizing pancreatitis: A systematic review and meta-analysis.

ObjectivesInterventions for necrotizing pancreatitis are generally postponed until 4 weeks after the onset of acute pancreatitis, but there remains controversy about whether we should always wait >4 weeks or can intervene early when necessary. This meta‐analysis was conducted to evaluate treatment outcomes of necrotizing pancreatitis according to the cut‐off defined in the revised Atlanta classification (≤4 vs. >4 weeks).MethodsUsing PubMed, Web of Science, and the Cochrane database, we identified clinical studies published until March 2022 with data comparing outcomes of early and delayed interventions of necrotizing pancreatitis. We pooled data on adverse events, mortality, technical and clinical success rates, and needs for necrosectomy and open surgery, using the random‐effects model.ResultsWe identified 11 retrospective studies, including 775 patients with early interventions and 725 patients with delayed interventions. Patients with early interventions tended to be complicated by organ failure. The rate of adverse events was comparable (OR 1.41, 95% CI 0.66–3.01; p = 0.38) but the rate of mortality was significantly higher (OR 1.70, 95% CI 1.21–2.40; p < 0.01) in early interventions. Technical success rates were similarly high but clinical success rates tended to be low (OR 0.39, 95% CI 0.15–1.00; p = 0.05) in early interventions, though not statistically significant. Pooled ORs for necrosectomy and open surgery were 2.14 and 1.23, respectively.ConclusionsEarly interventions for necrotizing pancreatitis were associated with higher mortality rates and did not reduce adverse events or improve clinical success. However, our results should be confirmed in prospective studies.

S38 Impact of Diabetes Mellitus on Acute Pancreatitis Outcomes in a Large Prospective Observational Cohort

Introduction: Acute pancreatitis (AP) is a leading indication for hospital admission. The relationship between AP and diabetes mellitus (DM) is becoming increasingly recognized. Many patients with DM have comorbid conditions (ex. heart and renal disease) that may increase the risk of severe pancreatitis or pancreatitis outcomes. We aim to identify the impact of DM on acute pancreatitis hospital outcomes including organ failure, readmission, and death. Methods: We identified patients hospitalized for acute pancreatitis between January 2015 and March 2021 using our prospective observational cohort. We included patients who had an episode of acute pancreatitis with or without pre-existing DM. Outcomes of interest included severity of pancreatitis, necessity of an intensive care unit (ICU) stay, organ failure, readmission, and death. Information on demographics, medical history, biochemical data, severity of the pancreatitis episode (Revised Atlanta Classification), and imaging were obtained for analysis. Logistic regression was used for analysis. Results: A total of 1340 unique patients were included in the analysis. 313 (23.4%) of the patients had pre-existing DM while 1027 (76.6%) did not. The overall cohort was 46.8% female and 81.3% Hispanic. The mean age in the patients with pre-existing DM was 53 ( ± 14) years old, while the non-diabetic cohort was 43 (± 15) years old. Patients with diabetes mellitus were significantly more likely to have moderate-to-severe pancreatitis [OR 1.52 (1.11-2.09)]. With regards to hospital outcomes, the diabetes cohort were more likely to have an intensive care unit (ICU) stay [2.26 (1.65-3.11)], and necessity of ICU interventions such as vasopressors [5.06 (2.25-11.38)], intubation [2.21 (1.13-4.35)], and renal replacement therapy (RRT) [4.77 (1.92-11.88)]. No significant difference was seen in readmission within 30 days [0.79 (0.51-1.23)] but patients with diabetes were more likely to have hospitalization result in death [3.49 (1.41-8.60)]. Conclusion: Within our acute pancreatitis population, patients with diabetes mellitus were more likely to have both local and systemic complications as well as necessity of more invasive hospital interventions such as intubation and vasopressors compared to their non-diabetic counterparts. These results emphasize the importance of adequately controlling patients’ underlying diabetes to minimize risk of hospital complications (Table). Table 1. - Comparison of hospitalization outcomes for acute pancreatitis in diabetics vs. non-diabetics No Diabetesn=1027, (76.6%) Diabetesn=313, (23.4%) P value OR (95% CI) Pancreatitis Severity Mild 857 (83.4%) 238 (76.0%) 0.003 Mod/Severe 170 (16.6%) 75 (24.0%) 0.003 1.52 (1.11-2.09) Organ Failure (any) 104 (10.1%) 54 (17.3%) 0.001 1.69 (1.16-2.44) Respiratory Failure 81 (7.9%) 34 (10.9%) 0.100 Circulatory Failure 20 (2.0%) 15 (4.8%) 0.006 Renal Failure 37 (3.6%) 33 (10.5%) < 0.0001 ICU Stay (yes/no) 138 (13.4%) 82 (26.2%) < 0.0001 2.26 (1.65-3.11) ICU LOHS (days) 0.8 1.5 0.031 Intubation 23 (2.2%) 16 (5.1%) 0.008 2.21 (1.13-4.35) Vasopressors 11 (1.1%) 17 (5.4%) < 0.0001 5.06 (2.25-11.38) RRT 9 (0.9%) 12 (3.8%) < 0.0001 4.77 (1.92-11.88) Readmission within 30 days 116 (11.3%) 29 (9.3%) 0.312 0.79 (0.51-1.23) Death 10 (1.0%) 12 (3.8%) < 0.0001 3.49 (1.41-8.60) Footnote: -OR=odds ratio, from multivariate analysis controlling for age, gender, and comorbidities such as heart failure, chronic kidney disease, and cirrhosis. ICU= intensive care unit; RRT = renal replacement therapy.

S96 Overutilization of Contrast-enhanced CT (CECT) Abdomen in the Diagnosis of Acute Pancreatitis (AP) in the Emergency Department (ED)

Introduction: AP is an inflammatory disorder of the pancreas which is one of the leading causes of gastrointestinal disorder admissions in the United States (US). As incidence of AP increases, so does the demand for effective means of diagnosis. According to revised Atlanta classification of 2012, typical abdominal pain in the epigastrium or left upper quadrant along with an elevated lipase level greater than 3-5 times the upper limit of normal is enough to diagnose AP. Contrast-enhanced CT (CECT) should only be obtained in cases of atypical presentation or failure to improve in 48-72 hours. However, availability of CECT has led to overutilization of its use in the diagnosis of AP, which can lead to delay in management, unnecessary radiation, and increased cost burden. Here we report a one-year data from a single medical center to assess utilization of CECT in the emergency department (ED) in the diagnosis of AP and if it changed management, length of stay (LOS), or outcomes. Methods: Data from 2018 to 2019 for all patients diagnosed with AP in the ED were analyzed. In total, 140 patients, 68 males and 72 females were analyzed. We evaluated lipase levels, CECT findings, LOS, and outcome. We used t-test to compare average means. Results: The most common etiology causing AP was alcohol abuse (37%), idiopathic (28%), gallstones (22%), followed by 8 cases due to drugs, 6 due to hypertriglyceridemia, 2 due to hypercalcemia, and 1 due to a pancreatic mass. All patients had presented with epigastric pain. Average lipase among all patients was 1727 U/L with a median of 530 U/L. CECT imaging was performed in 105 patients (75%). Among those who underwent CECT abdomen, 80 cases (76%) had positive finding for AP, while remaining 25 (24%) did not. Average lipase values were significantly elevated (2290 U/L vs 1732 U/L) among those who did not undergo CECT abdomen compared to those who did (P-value < 0.02). There were no statistical significance in both groups as far as management, LOS, hospitalization course, or outcomes. Conclusion: The purpose of this study was to assess how frequently was CECT used in the initial diagnosis in the ED setting and if it was helpful in changing management. Our results indicated that routine use of imaging in the diagnosis of AP is not necessary and has no impact on management and outcome. However, it can lead to increased radiation exposure and cost burden. Therefore, we recommend judicious use of CECT and recommend against routine utilization in the initial diagnosis of AP.

Pancreatic involvement due to immune checkpoint inhibitors: a proposed classification.

Drug-induced acute pancreatitis (AP) is uncommon and pancreatic involvement due to immune checkpoint inhibitors (ICI) in published reports relied on the National Cancer Institute's (NCI) Common Terminology Criteria for Adverse Events (CTCAE). CTCAE definition of AP differs from the revised Atlanta classification diagnostic criteria. This study aims to classify the spectrum of pancreatic involvement in patients receiving ICI therapy into categories built on the revised Atlanta classification. A retrospective cohort study of cancer patients receiving cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1) inhibitors between 2011 and 2020. Pancreas-specific immune-related adverse events (irAEs) were categorized into AP and pancreatic injury. Forty-seven patients on ICI therapy met selection criteria. Twenty patients (43%) had AP, while 27 (57%) had pancreatic injury. Fifteen patients (75%) developed mild AP. Five patients progressed to pancreatic atrophy, and two patients (4%) developed exocrine pancreatic insufficiency. In both groups, most patients received nivolumab therapy (70% vs. 67%, p = 0.08) with no difference in mean number of nivolumab doses (9 vs. 10, p = 0.69). There was no correlation between the mean number of nivolumab or pembrolizumab doses and AP events (OR 0.94, p = 0.26, and OR 0.98, p = 0.86), but the duration of ICI therapy was significantly related to pancreatic atrophy (OR 1.01, p = 0.05; 95% CI 1.00-1.02). Based on the novel classification, majority of pancreatic irAEs were classified as asymptomatic pancreatic injury but with some risk of pancreatic atrophy. This classification can help in assessing patterns of pancreatic involvement, pathogenesis, and treatment decisions.