Analyses of hospital administrative data that use diagnosis codes overestimate the cases of acute pancreatitis

Mechanisms linking hypertriglyceridemia to acute pancreatitis

Hypertriglyceridemia (HTG) is a metabolic disorder, defined when serum or plasma triglyceride concentration (seTG) is >1.7 mM. HTG can be categorized as mild to very severe groups based on the seTG value. The risk of acute pancreatitis (AP), a serious disease with high mortality and without specific therapy, increases with the degree of HTG. Furthermore, even mild or moderate HTG aggravates AP initiated by other important etiological factors, including alcohol or bile stone. This review briefly summarizes the pathophysiology of HTG, the epidemiology of HTG-induced AP and the clinically observed effects of HTG on the outcomes of AP. Our main focus is to discuss the pathophysiological mechanisms linking HTG to AP. HTG is accompanied by an increased serum fatty acid (FA) concentration, and experimental results have demonstrated that these FAs have the most prominent role in causing the consequences of HTG during AP. FAs inhibit mitochondrial complexes in pancreatic acinar cells, induce pathological elevation of intracellular Ca²⁺ concentration, cytokine release and tissue injury, and reduce the function of pancreatic ducts. Furthermore, high FA concentrations can induce respiratory, kidney, and cardiovascular failure in AP. All these effects may contribute to the observed increased AP severity and frequent organ failure in patients. Importantly, experimental results suggest that the reduction of FA production by lipase inhibitors can open up new therapeutic options of AP. Overall, investigating the pathophysiology of HTG-induced AP or AP in the presence of HTG and determining possible treatments are needed.

Hypertriglyceridemia-Induced Acute Pancreatitis - Course, Outcome, and Comparison with Non-Hypertriglyceridemia Associated Pancreatitis

Background

Although hypertriglyceridemia (HTG) is a well-established cause of acute pancreatitis (AP), there are no definitive management guidelines. Studies comparing clinical severity and outcome of hypertriglyceridemia-induced acute pancreatitis (HTGAP) and non- HTGAP are scarce. Hence, the present study was undertaken.

Materials and Methods

All consecutive patients admitted with AP from January 2017 to August 2021 at university teaching hospital were included in this study. Data with regards to patient demographics; clinical, laboratory, and radiologic parameters; management strategies; and outcome were collected and compared between HTGAP and non-HTGAP patients.

Results

Overall, 550 patients with AP were admitted during the study period, of which 21 (3.8%) were HTG related. Mean age of HTGAP patients was 34.3 years (M: F = 14:7), and the mean serum triglyceride (TG) levels on admission were 3,718.9 mg/dL (range 1,094-11,991). Insulin infusion therapy was used in 18 patients with HTGAP and the target TG levels of ≤500 mg/dL was achieved in 4.2 days (mean). Compared to non-HTGAP patients, HTGAP patients had higher body mass index (29.2 vs. 25.6), higher clinical (BISAP 2.6 vs. 2.06) and radiologic severity scores (CT severity score 7.5 v/s 4.8), and required prolonged hospital stay (12.9 vs. 6.5 days).

Conclusion

HTGAP occurred in young patients with high BMI and was associated with more severe disease, that required prolonged hospitalization than patients with non-HTGAP. Insulin infusion therapy was effective in reducing serum TG levels.

Hypertriglyceridemia-induced acute pancreatitis in children: A mini-review

Severe hypertriglyceridemia (HTG) is a known metabolic cause of acute pancreatitis (AP) in pediatric patients. The incidence of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) is less well established in pediatric compared to adult patients. Studies in adults suggest that higher risk of AP occurs when triglyceride levels (TG) are >1,000 mg/dL. Most common etiologies for severe HTG in pediatric patients are either from primary hypertriglyceridemia, underlying genetic disorders of lipid and TG metabolism, or secondary hypertriglyceridemia, separate disease or exposure which affects TG metabolism. Most common theories for the pathophysiology of HTG-AP include hydrolysis of TG by pancreatic lipase to free fatty acids leading to endothelial and acinar cell damage and ischemia, as well as hyperviscosity related to increased chylomicrons. Though there are varying reports of HTG-AP severity compared to other causes of AP, a steadily growing body of evidence suggests that HTG-AP can be associated with more severe course and complications. Therapeutic interventions for HTG-AP typically involve inpatient management with dietary restriction, intravenous fluids, and insulin; select patients may require plasmapheresis. Long term interventions generally include dietary modification, weight management, control of secondary causes, and/or antihyperlipidemic medications. Though some therapeutic approaches and algorithms exist for adult patients, evidence-based management guidelines have not been well established for pediatric patients.

Identification of Individuals at Increased Risk for Pancreatic Cancer in a Community-Based Cohort of Patients With Suspected Chronic Pancreatitis

We lack reliable methods for identifying patients with chronic pancreatitis (CP) at increased risk for pancreatic cancer. We aimed to identify radiographic parameters associated with pancreatic cancer in this population.

Trends and seasonality in hospitalizations for acute alcohol-related and biliary pancreatitis in the USA

BACKGROUND

The incidence of acute pancreatitis (AP) is characterized by circannual and geographical variation. The aim of this study was to describe seasonal variation and trends in hospitalizations for AP in the USA with respect to AP etiology.

METHODS

The Nationwide Inpatient Sample data (2000-2016) from the Healthcare Cost and Utilization Project were used. The study population included all primary hospitalizations for AP. Biliary AP (BAP) and alcohol-induced AP (AAP) were distinguished by diagnostic and procedural ICD codes. Seasonal trend decomposition was performed.

RESULTS

There was a linear increase in annual incidence (per 100 000 population) of AAP in the USA (from 17.0 in 2000 to 22.9 in 2016), while incidence of BAP, equaled 19.9 in 2000, peaked at 22.1 in 2006 and decreased to 17.4 in 2016. AP incidence demonstrated 18% annual incidence amplitude with summer peak and winter trough, more prominent in AAP. In 2016, within AAP, the highest incidence (per 100 000 population) was noted among African-Americans (up to 50.4), followed by males aged 56-70 years (26.5) and Asians of low income (25.5); within BAP, above the average incidence was observed in Hispanic (up to 25.8) and Asian (up to 25.0) population. The most consistent and rapid increase in AP incidence was noted in males aged 56-70 years with an alcoholic etiology (average 6% annual incidence growth).

CONCLUSIONS

The incidence and annual trends of AP vary significantly among demographic and socioeconomic groups and this knowledge may be useful for the planning of healthcare resources and identification of at-risk populations.

Predictors of hospital transfer and associated risks of mortality in acute pancreatitis

BACKGROUND

There is limited research in prognosticators of hospital transfer in acute pancreatitis (AP). Hence, we sought to determine the predictors of hospital transfer from small/medium-sized hospitals and outcomes following transfer to large acute-care hospitals.

METHODS

Using the 2010-2013 Nationwide Inpatient Sample (NIS), patients ≥18 years of age with a primary diagnosis of AP were identified. Hospital size was classified using standard NIS Definitions. Multivariable analyses were performed for predictors of "transfer-out" from small/medium-sized hospitals and mortality in large acute-care hospitals.

RESULTS

Among 381,818 patients admitted with AP to small/medium-sized hospitals, 13,947 (4%) were transferred out to another acute-care hospital. Multivariable analysis revealed that older patients (OR = 1.04; 95%CI 1.03-1.06), men (OR = 1.15; 95%CI 1.06-1.24), lower income quartiles (OR = 1.54; 95%CI 1.35-1.76), admission to a non-teaching hospital (OR = 3.38; 95%CI 3.00-3.80), gallstone pancreatitis (OR = 3.32; 95%CI 2.90-3.79), pancreatic surgery (OR = 3.14; 95%CI 1.76-5.58), and severe AP (OR = 3.07; 95%CI 2.78-3.38) were predictors of "transfer-out". ERCP (OR = 0.53; 95%CI 0.43-0.66) and cholecystectomy (OR = 0.14; 95%CI 0.12-0.18) were associated with decreased odds of "transfer-out". Among 507,619 patients admitted with AP to large hospitals, 31,058 (6.1%) were "transferred-in" from other hospitals. The mortality rate for patients "transferred-in" was higher than those directly admitted (2.54% vs. 0.91%, p < 0.001). Multivariable analysis revealed that being "transferred-in" from other hospitals was an independent predictor of mortality (OR = 1.47; 95% CI 1.22-1.77).

CONCLUSIONS

Patients with AP transferred into large acute-care hospitals had a higher mortality than those directly admitted likely secondary to more severe disease. Early implementation of published clinical guidelines, triage, and prompt transfer of high-risk patients may potentially offset these negative outcomes.

Incidence and Management of Hypertriglyceridemia-Associated Acute Pancreatitis: A Prospective Case Series in a Single Australian Tertiary Centre

BACKGROUND

Hypertriglyceridemia-associated acute pancreatitis (HTGAP) has been linked with increased severity and morbidity. In this study, triglyceride levels were measured in all patients admitted with acute pancreatitis (AP) to establish the incidence of HTGAP in an Australian center.

METHODS

A prospective cohort with AP was collated over an 18-month period in a single tertiary referral hospital. HTGAP was defined as AP with triglycerides ≥ 11.2 mmol/L (1000 mg/dL). Incidence, clinical co-morbidities, severity and management strategies were recorded.

RESULTS

Of the 292 episodes of AP, 248 (85%) had triglycerides measured and were included. HTGAP was diagnosed in 10 of 248 (4%) AP cases. Type 2 diabetes, obesity, alcohol misuse and gallstones were common cofactors. The HTGAP group demonstrated severe hypertriglyceridemia compared to the non-HTGAP group (median 51 mmol/L vs. 1.3 mmol/L). Intensive care unit (ICU) admissions were significantly increased (odds ratio (OR) 16; 95% CI 4-62) in the HTGAP group (5/10 vs. 14/238 admissions, p < 0.001) and constituted 26% (5/19) of total ICU admissions for AP. Four patients received intravenous insulin with fasting and had a rapid reduction in triglyceride levels by 65-77% within 24 h; one patient had mild hypoglycemia secondary to therapy.

CONCLUSION

HTGAP occurred in 4% of AP cases and was associated with higher risk of ICU admission. Intravenous insulin and fasting appear safe and efficacious for acutely lowering triglyceride levels in HTGAP.

Predictors and outcomes of acute respiratory failure in hospitalised patients with acute pancreatitis

BACKGROUND AND AIM

Acute pancreatitis (AP) is associated with organ failures and systemic complications, most commonly acute respiratory failure (ARF) and acute kidney injury. So far, no studies have analysed the predictors and hospitalisation outcomes, of patients with AP who developed ARF. The aim of this study was to measure the prevalence of ARF in AP and to determine the clinical predictors for ARF and mortality in AP.

METHODS

This is a retrospective cohort study using the Nationwide Inpatient Sample database from the year 2005-2014. The study population consisted of all hospitalisations with a primary or secondary discharge diagnosis of AP, which is further stratified based on the presence of ARF. The outcome measures include in-hospital mortality, hospital length of stay and hospitalisation cost.

RESULTS

In our study, about 5.4% of patients with AP had a codiagnosis of ARF, with a mortality rate of 26.5%. The significant predictors for ARF include sepsis, pleural effusion, pneumonia and cardiogenic shock. Key variables that were associated with a higher risk of mortality include mechanical ventilation, age more than 65 years, sepsis and cancer (excluding pancreatic cancer). The presence of ARF increased hospital stay by 8.3 days and hospitalisation charges by US$103 460.

CONCLUSION

In this study, we demonstrate that ARF is a significant risk factor for increased hospital mortality, greater length of stay and higher hospitalisation charges in patients with AP. This underlines significantly higher resource utilisation in patients with a dual diagnosis of AP-ARF.

Clinical features of hypertriglyceridemia-induced acute pancreatitis in an international, multicenter, prospective cohort (APPRENTICE consortium)

BACKGROUND

The clinical features and outcomes of hypertriglyceridemia-induced acute pancreatitis (HTG-AP) are not well-established.

OBJECTIVE

To evaluate the clinical characteristics of HTG-AP in an international, multicenter prospective cohort.

METHODS

Data collection was conducted prospectively through APPRENTICE between 2015 and 2018. HTG-AP was defined as serum TG levels >500 mg/dl in the absence of other common etiologies of AP. Three multivariate logistic regression models were performed to assess whether HTG-AP is associated with SIRS positive status, ICU admission and/or moderately-severe/severe AP.

RESULTS

1,478 patients were included in the study; 69 subjects (4.7%) were diagnosed with HTG-AP. HTG-AP patients were more likely to be younger (mean 40 vs 50 years; p < 0.001), male (67% vs 52%; p = 0.018), and with a higher BMI (mean 30.4 vs 27.5 kg/m2; p = 0.0002). HTG-AP subjects reported more frequent active alcohol use (71% vs 49%; p < 0.001), and diabetes mellitus (59% vs 15%; p < 0.001). None of the above risk factors/variables was found to be independently associated with SIRS positive status, ICU admission, or severity in the multivariate logistic regression models. These results were similar when including only the 785 subjects with TG levels measured within 48 h from admission.

CONCLUSION

HTG-AP was found to be the 4th most common etiology of AP. HTG-AP patients had distinct baseline characteristics, but their clinical outcomes were similar compared to other etiologies of AP.

Hypertriglyceridemia Induced Pancreatitis: Inpatient Management at a Single Pediatric Institution

OBJECTIVES

Hypertriglyceridemia-induced pancreatitis is an important cause of acute pancreatitis (AP) in children, which lacks established guidelines. The aim of this study was to review management approaches at a single pediatric center.

METHODS

This retrospective study included all inpatients younger than 21 years with AP and triglycerides (TG) of 1000 mg/dL or greater. A linear mixed effect model was used to calculate drop in TGs. The patient's diet, intravenous fluid (IVF) rate, insulin, and plasmapheresis were included in the model.

RESULTS

Seventeen admissions were identified among 8 patients, average age 15 years (range, 6-19 years). Fifty percent had recurrent AP and 29% of admissions had complications including 1 death. The population was primarily female (75%), white (75%), and overweight, and 63% had diabetes. The median stay was 5.4 days. There were 14 approaches used with variations in IVF rates, insulin, plasmapheresis, and nill per os (NPO) versus feeds. Variables that reduced TG's were NPO, higher IVF rates, plasmapheresis, and insulin (P < 0.05). Importantly, NPO reduced TGs faster than those who started early nutrition.

CONCLUSIONS

Hypertriglyceridemia is an important cause of pancreatitis in children. This study shares a management algorithm from a single institution. Larger studies are needed for more evidence-based guidelines.

Symptoms and Dietary Impact in Hypertriglyceridemia-Associated Pancreatitis: Development and Content Validity of Two New Measures

BACKGROUND

Severe hypertriglyceridemia (sHTG) is a rare condition, complicated by episodes of acute pancreatitis (AP), which can cause pain and/or life-threatening multi-organ dysfunction. Currently, there are no disease-specific patient-reported outcome (PRO) measures evaluating symptoms or dietary impact for this condition.

OBJECTIVE

The objective of this study was to explore patient-reported symptoms and impacts of sHTG and AP and develop new measures to capture the symptoms and dietary impacts of this condition using patient language.

METHODS

In-depth, semi-structured concept elicitation interviews were conducted with 12 US-based participants to explore their experience and identify key symptoms and impact on dietary behavior, both during and between episodes of AP. Participants had a range of AP severity with a previous triglyceride reading > 1000 mg/dL, and at least one attack of AP within the last 12 months. Transcripts were coded using thematic analysis.

RESULTS

Qualitative data analysis revealed the substantial burden of AP associated with sHTG. Participants reported experiencing symptoms, especially abdominal pain, both during and between attacks of AP, and discussed considerable diet changes to prevent or minimize future attacks. A conceptual model was refined, based on patient input, and reviewed by clinical experts to determine key concepts for inclusion within two PRO measures, one evaluating symptoms and another evaluating impact on dietary behavior. Items were drafted using patient-derived language. A 19-item symptoms measure [Hypertriglyceridemia and Acute Pancreatitis Symptom Scale (HAP-SS)] and a 6-item dietary impact measure (Hypertriglyceridemia and Acute Pancreatitis Dietary Behavior (HAP-DB) measure) were developed, both with a 24-h recall period.

CONCLUSIONS

The qualitative analysis confirmed the substantial burden of AP associated with sHTG. This research resulted in development of two disease-specific PRO measures for use during and between attacks of AP. These measures are being utilized in a clinical trial, which will confirm content, structure, and psychometric properties.

Opioid use disorder in admissions for acute exacerbations of chronic pancreatitis and 30-day readmission risk: A nationwide matched analysis

BACKGROUND

The opioid epidemic in the United States has been on the rise. Acute exacerbations of chronic pancreatitis (AECP) patients are at higher risk for Opioid Use Disorder (OUD). Evidence on OUD's impact on healthcare utilization, especially hospital re-admissions is scarce. We measured the impact of OUD on 30-day readmissions, in patients admitted with AECP from 2010 to 2014.

METHODS

This is a retrospective cohort study which included patients with concurrently documented CP and acute pancreatitis as first two diagnoses, from the National Readmissions Database (NRD). Pancreatic cancer patients and those who left against medical advice were excluded. We compared the 30-day readmission risk between OUD-vs.-non-OUD, while adjusting for other confounders, using multivariable exact-matched [(EM); 18 confounders; n = 28,389] and non-EM regression/time-to-event analyses.

RESULTS

189,585 patients were identified. 6589 (3.5%) had OUD. Mean age was 48.7 years and 57.5% were men. Length-of-stay (4.4 vs 3.9 days) and mean index hospitalization costs ($10,251 vs. $9174) were significantly higher in OUD-compared to non-OUD-patients (p < 0.001). The overall mean 30-day readmission rate was 27.3% (n = 51,806; 35.3% in OUD vs. 27.0% in non-OUD; p < 0.001). OUD patients were 25% more likely to be re-admitted during a 30-day period (EM-HR: 1.25; 95%CI: 1.16-1.36; p < 0.001), Majority of readmissions were pancreas-related (60%), especially AP. OUD cases' aggregate readmissions costs were $23.3 ± 1.5 million USD (n = 2289).

CONCLUSION

OUD contributes significantly to increased readmission risk in patients with AECP, with significant downstream healthcare costs. Measures against OUD in these patients, such as alternative pain-control therapies, may potentially alleviate such increase in health-care resource utilization.

Acute Biliary Pancreatitis is Associated With Adverse Outcomes in the Elderly: A Propensity Score-Matched Analysis

GOALS AND BACKGROUND

In the elderly (age, 65 y or older), acute pancreatitis is most frequently because of gallstones; however, there is a paucity of national estimates evaluating outcomes of acute biliary pancreatitis (ABP). Hence, we utilized a representative population database to evaluate the outcomes of ABP among the elderly.

STUDY

The National Readmission Database provides longitudinal follow-up of inpatients for 1 calendar-year. All adult inpatients (18 y or older) with an index primary admission for ABP between 2011 and 2014 were evaluated for clinical outcomes of mortality, severe acute pancreatitis (SAP), and 30-day readmission. Outcomes between age groups (≥65 vs. <65 y) were compared using multivariate and one-to-one propensity score-matched analyses.

RESULTS

Among 184,763 ABP admissions, 41% were elderly. Index mortality and SAP rates in the elderly were 1.96% and 21.5%, respectively. Elderly patients underwent more ERCPs (27.5% vs. 23.6%; P<0.001) and less frequent cholecystectomies (44.4% vs. 58.7%; P<0.001). Elderly patients had increased odds of mortality and SAP along with an age-dependent increase in the odds of adverse outcomes; patients aged 85 years or older demonstrated the highest odds of SAP [odds ratio (OR), 1.3; 95% confidence interval (CI): 1.2, 1.4] and mortality (OR, 2.2; 95% CI: 1.7, 2.9) within in the elderly cohort. Propensity score-matched analysis substantiated that mortality (OR, 2.8; 95% CI: 2.2, 3.5) and SAP (OR, 1.2; 95% CI: 1.1, 1.3) were increased in the elderly.

CONCLUSIONS

Current national survey reveals adverse clinical outcomes among elderly patients hospitalized with ABP. Consequently, there is a need for effective management strategies for this demographic as the aging population is increasing nationally.

Temporal Trends in Incidence and Outcomes of Acute Pancreatitis in Hospitalized Patients in the United States From 2002 to 2013

OBJECTIVES

We sought to examine temporal trends in incidence and outcomes of acute pancreatitis (AP) in hospitalized adult patients in the United States.

METHODS

Subjects were obtained from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database using International Classification of Diseases, Ninth Revision, Clinical Modification codes for the years 2002-2013. Incidence of AP, all-cause mortality, cost, and duration of hospitalization were assessed.

RESULTS

We identified 4,791,802 cases of AP. A significant increase in the incidence of AP was observed from 9.48 cases per 1000 hospitalizations in 2002 to 12.19 per 1000 hospitalizations in 2013 (P < 0.001). In-hospital mortality decreased from 2.99 cases per 100 cases in 2002 to 2.04 cases per 100 cases in 2013 (P < 0.001). Mean length of stay decreased from 6.99 (standard deviation [SD], 9.37) days in 2002 to 5.74 (SD, 7.94) days in 2013 (P < 0.001). Cost of hospitalization increased from $27,827 (SD, $54,556) in 2002 to $49,772 (SD, $106,205) in 2013 (P < 0.001).

CONCLUSIONS

Hospital admissions for AP in adults increased significantly in the United States from 2002 to 2013. In-hospital all-cause mortality and mean length of stay significantly decreased. In contrast, total cost of hospitalization rose.

Acute pancreatitis: Trends in outcomes and the role of acute kidney injury in mortality- A propensity-matched analysis

OBJECTIVES

To assess national trends of AP (acute pancreatitis) admissions, outcomes, prevalence of AKI (acute kidney injury) in AP, and impact of AKI on inpatient mortality.

METHODS

We queried the Nationwide Inpatient Sample database from 2003 to 2012 to identify AP admissions using ICD-9-CM codes. After excluding patients with missing information on age, gender, and inpatient mortality, we used ICD-9-CM codes to identify complications of AP, specifically AKI. We examined trends with survey-weighted multivariable regressions and analyzed predictors of AKI and inpatient mortality by multivariate logistic regression. Additionally, both AKI and non-AKI groups were propensity-matched and regressed against mortality.

RESULTS

A total of 3,466,493 patients (1.13% of all discharges) were hospitalized with AP, of which 7.9% had AKI. AP admissions increased (1.02%→1.26%) with rise in concomitant AKI cases (4.1%→11.7%) from year 2003-2012. Mortality rate decreased (1.8%→1.1%) in the AP patients with a substantial decline noted in AKI subgroup (17.4%→6.4%) during study period. Length of stay (LOS) and cost of hospitalization decreased (6.1→5.2 days and $13,654 to $10,895, respectively) in AKI subgroup. Complications such as AKI (OR: 6.08, p < 0.001), septic shock (OR: 46.52, p < 0.001), and acute respiratory failure (OR: 22.72, p < 0.001) were associated with higher mortality. AKI, after propensity matching, was linked to 3-fold increased mortality (propensity-matched OR: 3.20, P < 0.001).

CONCLUSION

Mortality, LOS, and cost of hospitalization in AP has decreased during the study period, although hospitalization and AKI prevalence has increased. AKI is independently associated with higher mortality.

The Use of International Classification of Diseases Codes to Identify Patients with Pancreatitis: A Systematic Review and Meta-analysis of Diagnostic Accuracy Studies

Background

Hospital discharge codes are increasingly used in gastroenterology research, but their accuracy in the setting of acute pancreatitis (AP) and chronic pancreatitis (CP), one of the most frequent digestive diseases, has never been assessed systematically. The aim was to conduct a systematic literature review and determine accuracy of diagnostic codes for AP and CP, as well as the effect of covariates.

Methods

Three databases (Pubmed, EMBASE and Scopus) were searched by two independent reviewers for relevant studies that used International Classification of Disease (ICD) codes. Summary estimates of sensitivity, specificity and positive predictive value were obtained from bivariate random-effects regression models. Sensitivity and subgroup analyses according to recurrence of AP and age of the study population were performed.

Results

A total of 24 cohorts encompassing 18,106 patients were included. The pooled estimates of sensitivity and specificity of ICD codes for AP were 0.85 and 0.96, respectively. The pooled estimates of sensitivity and specificity of ICD codes for CP were 0.75 and 0.94, respectively. The positive predictive value of ICD codes was 0.71 for either AP or CP. It increased to 0.78 when applied to incident episode of AP only. The positive predictive value decreased to 0.68 when the ICD codes were applied to paediatric patients.

Conclusion

Nearly three out of ten patients are misidentified as having either AP or CP with the indiscriminate use of ICD codes. Limiting the use of ICD codes to adult patients with incident episode of AP may improve identification of patients with pancreatitis in administrative databases.

The Type of Bariatric Surgery Impacts the Risk of Acute Pancreatitis: A Nationwide Study

OBJECTIVE

We investigated whether vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass surgery (RYGB) have a differential impact on post-operative risk of acute pancreatitis (AP).

METHODS

This retrospective study uses the 2012-2014 National Readmission Database. We compared morbidly obese patients who underwent VSG (n = 205,251), RYGB (n = 169,973), and hernia repair (HR) control (n = 16,845). Our main outcome was rates of AP within 6 months post- vs. 6 months pre-surgery in VSG, RYGB, and HR. We also investigated risk factors and outcomes of AP after bariatric surgery.

RESULTS

The rates of AP increased post- vs. pre-VSG (0.21% vs. 0.04%; adjusted odds ratio [aOR] = 5.16, P < 0.05) and RYGB (0.17% vs. 0.07%; aOR = 2.26, P < 0.05) but not post-HR. VSG was associated with a significantly greater increase in AP risk compared to RYGB (aOR = 2.28; 95% CI: 1.10, 4.73). Furthermore, when compared to HR controls, only VSG was associated with a higher AP risk (aOR = 7.58; 95% CI: 2.09, 27.58). Developing AP within 6 months following bariatric surgery was mainly associated with younger age (18-29 years old: aOR = 3.76 for VSG and aOR: 6.40 for RYGB, P < 0.05) and gallstones (aOR = 85.1 for VSG and aOR = 46 for RYGB, P < 0.05). No patients developed "severe AP" following bariatric surgery.

CONCLUSIONS

More patients develop AP within 6 months after VSG compared to RYGB and controls. This risk is highest for younger patients and those with gallstones. Prospective studies examining mechanisms and prevention are warranted.

Cholecystectomy During Index Admission for Acute Biliary Pancreatitis Lowers 30-Day Readmission Rates

OBJECTIVES

Few studies have evaluated national readmission rates after acute pancreatitis (AP) in the United States. We sought to evaluate modifiable factors impacting 30-day readmissions after AP hospitalizations.

METHODS

We used the Nationwide Readmission Database (2013) involving all adults with a primary discharge diagnosis of AP. Multivariable logistic regression models assessed independent predictors for specific outcomes.

RESULTS

Among 180,480 patients with AP index admissions, 41,094 (23%) had biliary AP, of which 10.5% were readmitted within 30 days. The 30-day readmission rate for patients who underwent same-admission cholecystectomy (CCY) was 6.5%, compared with 15.1% in those who did not (P < 0.001). Failure of index admission CCY increased the risk of readmissions (odds ratio [OR], 2.27; 95% confidence interval [CI], 2.04-2.56). Same-admission CCY occurred in 55% (n = 19,274) of patients without severe AP. Severe AP (OR, 0.73; 95% CI, 0.65-0.81), sepsis (OR, 0.63; 95% CI, 0.52-0.75), 3 or more comorbidities (OR, 0.74; 95% CI, 0.68-0.79), and admissions to small (OR, 0.76; 95% CI, 0.64-0.91) or rural (OR, 0.78; 95% CI, 0.65-0.95) hospitals were less likely to undergo same-admission CCY.

CONCLUSIONS

Same-admission CCY should be considered in patients with biliary AP when feasible. This national appraisal recognizes modifiable risk factors to reduce readmission in biliary AP and reinforces adherence to major society guidelines.

Type V hypertriglyceridemia in children, a therapeutic challenge in pediatrics: A case report and a review of the literature

RATIONALE

Hypertriglyceridemia is defined as a level of triglycerides above 150 mg/dL. The complex causes and classification of hypertriglyceridemia lead to difficulties in the diagnosis and management of this condition.

PATIENT CONCERNS

We present the case of a 15 years and 6 months old female teenager, admitted in our clinic for the following complaints: severe abdominal pain predominantly in the lateral left quadrant, nausea, vomiting, and the lack of stools for 2 days. The clinical exam showed: impaired general status, painful abdomen at superficial and deep palpation in the left and upper abdominal quadrants, the absence of stools for 2 days.

DIAGNOSES

The laboratory parameters revealed leukocytosis with neutrophilia, thrombocytopenia, high level of serum amylase and triglycerides, and increased inflammatory biomarkers. The imagistic investigations showed ascites and paralytic ileus.

INTERVENTIONS

The management was burdened by the side-effects of hypolipidemic drugs impairing the liver function and leading to rhabdomyolysis, but eventually the patient's outcome was good.

OUTCOMES

Type V hyperlipoproteinemia is a rare condition accounting for approximately 5% of the cases. The risk for acute pancreatitis is well-known to be associated with hypertriglyceridemia, even though in rare cases.

LESSONS

The prognosis of hypertriglyceridemia is pediatrics is burdened not only by the long-term risk factors associated to the diseases itself, but also by the negative effects of long-term hypolipidemic treatment.

Risk of Pancreatic Cancer After a Primary Episode of Acute Pancreatitis

OBJECTIVE

Acute pancreatitis may be the first manifestation of pancreatic cancer. The aim of this study was to assess the risk of pancreatic cancer after a first episode of acute pancreatitis.

METHODS

Between March 2004 and March 2007, all consecutive patients with a first episode of acute pancreatitis were prospectively registered. Follow-up was based on hospital records audit, radiological imaging, and patient questionnaires. Outcome was stratified based on the development of chronic pancreatitis.

RESULTS

We included 731 patients. The median follow-up time was 55 months. Progression to chronic pancreatitis was diagnosed in 51 patients (7.0%). In this group, the incidence rate per 1000 person-years for developing pancreatic cancer was 9.0 (95% confidence interval, 2.3-35.7). In the group of 680 patients who did not develop chronic pancreatitis, the incidence rate per 1000 person-years for developing pancreatic cancer in this group was 1.1 (95% confidence interval, 0.3-3.3). Hence, the rate ratio of pancreatic cancer was almost 9 times higher in patients who developed chronic pancreatitis compared with those who did not (P = 0.049).

CONCLUSIONS

Although a first episode of acute pancreatitis may be related to pancreatic cancer, this risk is mainly present in patients who progress to chronic pancreatitis.

The Changing Epidemiology of Acute Pancreatitis Hospitalizations: A Decade of Trends and the Impact of Chronic Pancreatitis

OBJECTIVES

The epidemiological trends contributing to increasing acute pancreatitis (AP) hospitalizations remain unknown. We sought to analyze etiological factors and outcomes of increasing AP hospitalizations.

METHODS

Utilizing the Nationwide Inpatient Sample, retrospective analyses of adult (≥18 years) inpatient admissions with a primary diagnosis of AP (N = 2,016,045) were performed. Patient hospitalizations from 2009 to 2012 were compared with those from 2002 to 2005.

RESULTS

Compared with 2002-2005, there was a 13.2% (P < 0.001) increase in AP admissions in 2009-2012. Multivariate analysis adjusted for "period," patient and hospital demographics, AP etiologies, and disease associations demonstrated an increase in the odds of associated chronic pancreatitis (CP) [2002-2005: odds ratio, (OR), 32.04; 95% confidence interval (CI), 30.51-33.64; 2009-2012: OR, 35.02; 95% CI, 33.94-36.14], whereas associated odds of gallstones (2002-2005: OR, 36.37; 95% CI, 35.32-37.46; 2009-2012: OR, 29.85; 95% CI, 29.09-30.64) decreased. Compared with 2002-2005, the AP-related mortality decreased in 2009-2012 (1.62%-0.79%, P < 0.001) and was lower in AP with associated CP (0.65%-0.26%; P < 0.001) compared with AP without CP.

CONCLUSION

In the preceding decade, AP hospitalizations increased, but associated mortality declined. Associated CP has emerged as a leading contributor for AP-related hospitalizations. Further research is needed to identify novel interventions to prevent disease progression of AP.

Therapeutic plasmapheresis for hypertriglyceridemia-associated acute pancreatitis: case series and review of the literature

BACKGROUND

Severe hypertriglyceridemia (HTG) is the third leading cause of acute pancreatitis (AP) in the United States. The current standard of care includes management of HTG using pharmacological therapy. More recently, plasmapheresis has been proposed as a therapeutic tool for decreasing triglyceride (TG) levels, especially in critically ill patients. Few studies are available to ascertain overall benefits of plasmapheresis over traditional management.

OBJECTIVE

To analyze the outcomes of patients treated with plasmapheresis for severe HTG-associated pancreatitis.

METHODS

We conducted a retrospective chart review of three patients with severe HTG- associated (TGs greater than 1000 mg/dl; 11.29 mmol/l) AP at the Methodist University Hospital. All the patients underwent plasmapheresis as part of their treatment.

RESULTS

The average TG level before plasmapheresis was 3532 mg/dl (range: 2524-4562 mg/dl; 39.9 mmol/l; range: 28.5-51.6 mmol/l). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 1.3 (range 1-2), and mean TG level after plasmapheresis was 1051 mg/dl (range: 509-1771 mg/dl; 11.9 mmol/l; range: 5.8-20 mmol/l). After the first session, the average reduction of TG level was 2481 mg/dl (range 753-3750 mg/dl; 28 mmol/l; range: 8.5-42.4 mmol/l) or approximately 70%. None of the patients developed complications related to plasmapheresis.

CONCLUSIONS

Plasmapheresis can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.

Low Alcohol and Cigarette Use Is Associated to the Risk of Developing Chronic Pancreatitis

OBJECTIVES

The aim of this study was to investigate the contribution of smoking and alcohol intake and pancreas divisum on the risk of developing chronic pancreatitis (CP).

METHODS

Consecutive patients with CP who underwent secretin-enhanced magnetic resonance cholangiopancreatography were compared with consecutive patients without pancreatic disease who underwent secretin-enhanced magnetic resonance cholangiopancreatography for irritable bowel syndrome.

RESULTS

We enrolled 145 consecutive CP patients and 103 irritable bowel syndrome patients from 2010 to 2014. In a univariate analysis, statistically significant differences in sex, mean age, and the duration and amount of cigarette and alcohol use were found. Per a receiver operating characteristic curve analysis, thresholds for cigarette and alcohol consumption were, respectively, 5.5 cigarettes and 13.5 g daily. In a multivariate analysis, independent risk factors for CP were male sex (odds ratio [OR], 2.05), smoking more than 5.5 cigarettes per day (OR, 2.72), and drinking more than 13.5 g/d (OR, 6.35).

CONCLUSIONS

In an Italian population, we confirmed smoking and alcohol as cofactors in the development of CP. This study shows that alcohol intake and smoking habits are 2 of the most important risk factors for the development of CP.

Dietary Factors Reduce Risk of Acute Pancreatitis in a Large Multiethnic Cohort

BACKGROUND & AIMS

Pancreatitis is a source of substantial morbidity and health cost in the United States. Little is known about how diet might contribute to its pathogenesis. To characterize dietary factors that are associated with risk of pancreatitis by disease subtype, we conducted a prospective analysis of 145,886 African Americans, Native Hawaiians, Japanese Americans, Latinos, and whites in the Multiethnic Cohort.

METHODS

In the Multiethnic Cohort (age at baseline, 45-75 y), we identified cases of pancreatitis using hospitalization claim files from 1993 through 2012. Patients were categorized as having gallstone-related acute pancreatitis (AP) (n = 1210), AP not related to gallstones (n = 1222), or recurrent AP or suspected chronic pancreatitis (n = 378). Diet information was obtained from a questionnaire administered when the study began. Associations were estimated by hazard ratios and 95% confidence intervals using Cox proportional hazard models adjusted for confounders.

RESULTS

Dietary intakes of saturated fat (P trend = .0011) and cholesterol (P trend = .0008) and their food sources, including red meat (P trend < .0001) and eggs (P trend = .0052), were associated positively with gallstone-related AP. Fiber intake, however, was associated inversely with gallstone-related AP (P trend = .0005) and AP not related to gallstones (P trend = .0035). Vitamin D, mainly from milk, was associated inversely with gallstone-related AP (P trend = .0015), whereas coffee consumption protected against AP not related to gallstones (P trend < .0001). With the exception of red meat, no other dietary factors were associated with recurrent acute or suspected chronic pancreatitis.

CONCLUSIONS

Associations between dietary factors and pancreatitis were observed mainly for gallstone-related AP. Interestingly, dietary fiber protected against AP related and unrelated to gallstones. Coffee drinking protected against AP not associated with gallstones. Further studies are warranted to confirm our findings.

Clinical Profile and Natural Course in a Large Cohort of Patients With Hypertriglyceridemia and Pancreatitis

GOALS

To report the clinical profile and natural course in a large series of patients with hypertriglyceridemia (HTG) and acute pancreatitis (AP).

BACKGROUND

The natural history of HTG-related pancreatitis is poorly defined.

STUDY

Medical records of 121 patients with serum triglycerides (TG) levels of ≥500 mg/dL suffering 225 attacks of AP between January 2001 to August 2013 treated at the University of Pittsburgh Medical Center were retrospectively studied. Structured data were collected on initial presentation and long-term outcomes (mean follow-up 64.7±42.8 mo). AP severity was classified using Revised Atlanta Classification.

RESULTS

Most patients were young-middle aged (mean 44±12.7 y), male (70%), white (78%), and had sentinel AP (63%). Peak serum TG recorded was ≥1000 mg/dL in 48%. At least 1 secondary risk factor (diabetes, high-risk drinking, obesity, offending medications) was present in the majority (78%). Sentinel AP attack varied in severity between mild (41%), moderate (26%), and severe (33%). Recurrent AP attacks occurred in 32%, often in patients with poorly controlled diabetes, alcoholism, and TG levels. A cumulative increase in prevalence of pancreatic and/or peripancreatic necrosis was observed, with 45% patients having it at some time during observation. Local complications were higher in patients with serum TG ≥1000 mg/dL. Chronic pancreatitis was noted in 16.5% patients (new-onset in 9%).

CONCLUSIONS

Patients with HTG-related pancreatitis have a high prevalence of secondary risk factors. Frequent recurrences in them are usually due to poor control of secondary factors or TG. Serum TG ≥1000 mg/dL increases the risk of local complications. A subset can have or develop chronic pancreatitis.

Relationship between Plasma Triglyceride Level and Severity of Hypertriglyceridemic Pancreatitis

Background

Hypertriglyceridemia is the third most common cause of acute pancreatitis, but whether the level of triglyceride (TG) is related to severity of pancreatitis is unclear.

Aim

To evaluate the effect of TG level on the severity of hypertriglyceridemic pancreatitis (HTGP).

Design

Retrospective cohort study.

Methods

We reviewed the records of 144 patients with HTGP from 1999 to 2013 at Tri-Service General Hospital. Patients with possible etiology of pancreatitis, such as gallstones, those consuming alcohol or drugs, or those with infections were excluded. The classification of severity of pancreatitis was based on the revised Atlanta classification. We allocated the patients into high-TG and low-TG groups based on the optimal cut-off value (2648 mg/dL), which was derived from the receiver operating characteristic (ROC) curve between TG level and severity of HTGP. We then compared the clinical characteristics, pancreatitis severity, and mortality rates of the groups.

Results

There were 66 patients in the low-TG group and 78 patients in the high-TG group. There was no significant difference in the age, sex ratio, body mass index, and comorbidity between the 2 groups. The high-TG group had significantly higher levels of glucose (P = 0.022), total cholesterol (P = 0.002), and blood urea nitrogen (P = 0.037), and lower levels of sodium (P = 0.003) and bicarbonate (P = 0.002) than the low-TG group. The incidences of local complication (P = 0.002) and severe and moderate form of pancreatitis (P = 0.004) were significantly higher in the high-TG group than in the low-TG group. The mortality rate was higher in the high-TG group than in the low-TG group (P = 0.07).

Conclusions

Higher TG level in patients with HTGP may be associated with adverse prognosis, but randomized and prospective studies are needed in the future verify this relationship.

The Chronic Pancreatitis International Classification of Diseases, Ninth Revision, Clinical Modification Code 577.1 Is Inaccurate Compared With Criterion-Standard Clinical Diagnostic Scoring Systems

OBJECTIVES

Epidemiological studies utilizing administrative databases use the International Classification of Diseases, Ninth Revision, Clinical Modification code (577.1) to identify patients with chronic pancreatitis (CP). We hypothesized that coding of CP in these databases is inaccurate.

METHODS

We retrospectively reviewed the records of 1343 consecutive patients having an International Classification of Diseases, Ninth Revision, Clinical Modification code 577.1 between October 1, 2005, and November 1, 2008. We labeled patients as definite CP or non-CP, defined as fulfilling any of the 3 diagnostic criteria for definite CP: Mayo, Ammann's, and the Japanese Pancreas Society criteria.

RESULTS

Six hundred fifty-eight subjects (49%) had definite CP. Definite CP among Mayo, Ammann's, and Japanese Pancreas Society criteria was similar (49.0, 42.1, and 43.8, respectively); 84.3% of the definite CP fulfilled all 3 criteria, 6.7% fulfilled 2, and 9.0% filled 1 criterion. Etiologies of definite CP were definite/suspected nonalcohol (57.8%) or alcohol (33.5%) and not reported (8.7%). In non-CP (n = 685), 93.7% had available imaging (5.7% had endoscopic ultrasonography ≥5 or Cambridge II-III scores), and 63.5% had symptoms suggestive of CP but did not fulfill other features for definite CP. The CP versus non-CP groups had similar mean ages but significantly more men and patients ever smoking and ever drinking alcohol.

CONCLUSIONS

Fifty-one percent of subjects coded as CP do not fulfill the diagnostic criteria for definite CP. Relying solely on the International Classification of Diseases, Clinical Modification code for CP in administrative databases may lead to erroneous epidemiological conclusions.

Prospective Study of Alcohol Drinking, Smoking, and Pancreatitis: The Multiethnic Cohort

OBJECTIVES

We conducted a prospective analysis of 145,886 participants in the multiethnic cohort to examine the relationship of alcohol drinking and smoking with pancreatitis.

METHODS

Pancreatitis cases were categorized as gallstone-related acute pancreatitis (GSAP) (N = 1,065), non-GSAP (N = 1,222), and recurrent acute (RAP)/chronic pancreatitis (CP) (N = 523). We used the baseline questionnaire to identify alcohol intake and smoking history. Associations were estimated by hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox models.

RESULTS

Cigarette smoking was associated with non-GSAP and RAP/CP. Moderate alcohol intake was inversely associated with all types of pancreatitis in women (HRs, 0.66 to 0.81 for <1 drink per day), and with RAP/CP in men (HR, 0.57; 95% CI, 0.41-0.79 for <2 drinks per day). The risk of non-GS pancreatitis associated with current smoking was highest among men who consumed more than 4 drinks per day (HR, 2.06; 95% CI, 1.28-3.30), whereas among never smokers, moderate drinking was associated with a reduced risk (HR, 0.70; 95% CI, 0.51-0.96). In women, drinking less than 2 drinks per day was associated with a reduced risk of GSAP among never smokers (HR, 0.61; 95% CI, 0.46-0.80).

CONCLUSIONS

Smoking is a risk factor for non-GS pancreatitis. Moderate alcohol intake is protective against all types of pancreatitis in women and against RAP/CP in men.

Therapeutic plasma exchange for hypertriglyceridemia induced pancreatitis: A rapid and practical approach

OBJECTIVES

Acute hypertriglyceridemia induced pancreatitis (HTP) presents with a more severe clinical course compared to other etiologies of pancreatitis. Therapeutic plasma exchange (TPE) is a potential treatment option for lowering plasma triglycerides and possibly decreasing morbidity and mortality. However, clinical data regarding its effectiveness are limited.

METHODS

We retrospectively examined the clinical data and outcomes of 13 consecutive episodes of HTP in which TPE was employed to reduce plasma triglycerides during a 15-month period.

RESULTS

The TPE was initiated at a median of 19 hours from the time of presentation. We performed 1.2-1.5 volume TPEs with 5% albumin as the replacement fluid. After only one TPE procedure, the mean plasma triglycerides values decreased from 2993 mg/dl to 487 mg/dl with a reduction of 84%. All 13 patients survived with a mean length of hospital stay of 9.5 days. There were no complications related to TPE.

CONCLUSIONS

One TPE procedure is an effective method for reducing plasma triglycerides and possibly decreases the length of hospital stay in patients admitted with HTP.

Clinical Study of 224 Patients with Hypertriglyceridemia Pancreatitis

BACKGROUND

Hypertriglyceridemia (HTG) is the most common etiology of acute pancreatitis (AP) after alcohol and gallstone-induced disease. Elevation of serum triglyceride (TG) levels to ≥ 1000 mg/dl in a patient with AP strongly indicates HTG as the cause. The absolute risk of pancreatitis based on serum TG ≤ 1000 mg/dl has not been clearly defined. The aims of this study were to address the role of elevated TG levels between 500 and 1000 mg/dl in the clinical course of HTG pancreatitis (HTGP); and assess the relationship between the level of serum TG and disease severity.

METHODS

A total of 224 HTGP patients between 2007 and 2011 were divided into two subgroups. Totally, 122 patients in Group A had serum TG >1000 mg/dl; 102 patients in Group B had maximal TG levels between 500 and 1000 mg/dl accompanied by lactescent serum; 100 patients with biliary AP and 99 patients with alcoholic AP hospitalized during the study period were enrolled as controls. The clinical and biochemical data were analyzed.

RESULTS

The clinical presentation of HTG-induced pancreatitis was similar to other causes. Severe form of AP in Group A was higher than Group B (χ2 = 4.002, P = 0.045). The severity with HTGP was significantly higher as compared to biliary AP (χ2 = 33.533, P = 0.000) and alcoholic AP (χ2 = 7.179, P = 0.007). Systemic complications with HTGP were significantly higher than biliary AP (χ2 = 58.763, P = 0.000).

CONCLUSIONS

The study demonstrated that TG level ≥ 500 mg/dl should raise a high degree of suspicion, especially if no other etiology of AP is apparent. The severity of HTGP seems to correlate directly with TG level. HTGP seems be more severe than other causes of AP.

A single-centre prospective, cohort study of the natural history of acute pancreatitis

BACKGROUND

The natural history of acute pancreatitis is based on clinical studies that aim to elucidate the course of disease on the basis of predicted risk factors.

AIMS

To evaluate the long-term occurrence of recurrent acute pancreatitis and chronic pancreatitis in a cohort of patients following an initial episode of acute pancreatitis.

METHODS

196 patients were enrolled consecutively and studied prospectively. Clinical characteristics, exogenously/endogenously-associated factors, and evolution to recurrent acute pancreatitis and chronic pancreatitis were analyzed.

RESULTS

40 patients developed recurrent acute pancreatitis 13 of whom developed chronic pancreatitis. In a univariate analysis, recurrent acute pancreatitis was associated with an idiopathic aetiology (p<0.001), pancreas divisum (p=0.001), and higher usage of cigarettes and alcohol (p<0.001; p=0.023). Chronic pancreatitis was associated with a severe first episode of acute pancreatitis (p=0.048), PD (p=0.03), and cigarette smoking (p=0.038). By multivariate analysis, pancreas divisum was an independent risk factor for recurrent acute pancreatitis (OR 11.5, 95% CI 1.6-83.3). A severe first-episode of acute pancreatitis increased the risk of progressing to chronic pancreatitis by nine-fold.

CONCLUSIONS

Special attention should be given to patients who experience a severe first attack of acute pancreatitis as there appears to be an increased risk of developing chronic pancreatitis over the long term.

Simvastatin is associated with reduced risk of acute pancreatitis: findings from a regional integrated healthcare system

OBJECTIVE

To characterise the relationship between simvastatin and risk of acute pancreatitis (AP).

DESIGN

We conducted a retrospective cohort study (2006-2012) on data from an integrated healthcare system in southern California. Exposure to simvastatin was calculated from time of initial dispensation until 60 days following prescription termination. AP cases were defined by ICD-9 CM 577.0 and serum lipase≥3 times normal. Patients were censored at death, last follow-up, and onset of AP or end-of-study. Incidence rate of pancreatitis among simvastatin users was compared with the adult reference population. Robust Poisson regression was used to generate risk ratio (RR) estimates for simvastatin use adjusted for age, gender, race/ethnicity, gallstone-related disorders, hypertriglyceridaemia, smoking and alcohol dependence. Analysis was repeated for atorvastatin.

RESULTS

Among 3,967,859 adult patients (median duration of follow-up of 3.4 years), 6399 developed an initial episode of AP. A total of 707,236 patients received simvastatin during the study period. Patients that received simvastatin were more likely to have gallstone-related disorders, alcohol dependence or hypertriglyceridaemia compared with the reference population. Nevertheless, risk of AP was significantly reduced with simvastatin use, crude incidence rate ratio 0.626 (95% CL 0.588, 0.668), p<0.0001. In multivariate analysis, simvastatin was independently associated with reduced risk of pancreatitis, adjusted RR 0.29 (95% CL 0.27, 0.31) after adjusting for age, gender, race/ethnicity, gallstone disorders, alcohol dependence, smoking and hypertriglyceridaemia. Similar results were noted with atorvastatin, adjusted RR 0.33(0.29, 0.38).

CONCLUSIONS

Use of simvastatin was independently associated with reduced risk of AP in this integrated healthcare setting. Similar findings for atorvastatin suggest a possible class effect.

Risk factors and outcome of splanchnic venous thrombosis in patients with necrotizing acute pancreatitis

BACKGROUND

Splanchnic venous thrombosis (SVT) is considered a rare but important complication in patients with acute pancreatitis (AP) and literatures regarding this topic were sparse. The aim of the present study was to investigate the risk factors of SVT in necrotizing acute pancreatitis (NAP) and assess the prognosis of these patients.

METHODS

Both univariate and multivariate logistic regression analyses were applied using 15 indices including age, gender, Acute Physiology and Chronic Health Evaluation II scores (APACHE II), CRP (C - reactive protein) levels, etc to explore potential risk factors for the development of SVT in NAP patients. Moreover, clinical outcome measures such as mortality, organ failure and length of hospital and ICU stay were also compared between NAP patients with or without SVT.

RESULTS

According to the statistical results, only intra-abdominal pressure (IAP) was proved to be an independent risk factor for SVT (OR, 1.283; 95% CI, 1.091-1.509,P=0.003). In addition, Balthazar's CT score and occurrence of IPN (infected pancreatic necrosis) also reached statistical significance (P=0.040 and 0.047, respectively), but the 95% confidence interval shown in the multivariate logistic regression suggested that the observed ORs are not significant (1.326;95% CI 0.984-1.787 and 2.61;95 CI 0.972-7.352, respectively), which indicates weaker association between the two parameters and SVT. Regarding the clinical outcomes, patients with SVT showed higher mortality, longer hospital and intensive care unit duration, higher rates of a variety of complications and more utilization of invasive interventions.

CONCLUSIONS

IAP is an independent risk factor for the development of SVT in patients with NAP, while Balthazar's CT score and occurrence of IPN are also associated with SVT, although not as strong as IAP. Moreover, occurrence of SVT relates with extremely poor prognosis in NAP patients, evidenced by increased mortality, morbidity and need for invasive interventions.

A population-based evaluation of severity and mortality among transferred patients with acute pancreatitis

OBJECTIVES

This study aimed to compare severity of acute pancreatitis (AP) and mortality rates between transferred and nontransferred patients and to determine the factors that influence the decision to transfer.

METHODS

A retrospective analysis coding a statewide administrative database in Maryland was conducted. Severity was defined by presence of organ failure (OF), need for intensive care unit (ICU), mechanical ventilation (MV), or hemodialysis.

RESULTS

There were 71,035 discharges for AP, with 1657 (2.3%) patient transfers. Transferred patients had more multisystem OF (5.6% vs 1.2%), need for ICU (22.8% vs 4.3%), MV (13.1% vs 1.4%), hemodialysis (4.2% vs 2.7%), and higher mortality (6.1% vs 1.1%) compared with nontransferred patients (P < 0.0001). After adjusting for disease severity, mortality was similar between the transferred patients and the nontransferred patients (OR, 1.37; 95% confidence interval, 0.96-1.97). Younger (OR, 0.99), African American (OR, 0.55), and uninsured (OR, 0.46) patients were less likely to be transferred, whereas patients with multisystem OF (OR, 3.5), need for ICU (OR, 2.3), or MV (OR, 2.1) were more likely to be transferred (P < 0.0001).

CONCLUSIONS

Transferred patients with AP have more severe disease and higher overall mortality. Mortality is similar after adjusting for disease severity. Disease severity, insurance status, race, and age all influence the decision to transfer patients with AP.

Early phase of acute pancreatitis: Assessment and management

Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.

A population-based assessment of the burden of acute pancreatitis in the United States

OBJECTIVES

The aim of this study is to investigate the incidence and mortality of emergency department (ED) visits in the United States attributed to acute pancreatitis (AP) and quantify predictors of admission and mortality.

METHODS

Using the nationwide ED sample, all ED visits between 2006 and 2009 for AP were extracted. Multivariable analyses were fitted for prediction of admission and mortality.

RESULTS

A weighted sample of 1,224,121 patient visits with AP was captured. Of those, 75.4% resulted in admission and 0.7% died. Between 2006 and 2009, the incidence of AP ED visits increased from 9.9 to 10.6 per 10,000 person-years. Patients were more likely to be admitted if sicker (Charlson Comorbidity Index score ≥ 3; OR, 6.48; P < 0.001) and if the etiology of pancreatitis was alcoholic versus biliary (OR, 2.20; P < 0.001). They were more likely to die if sicker (Charlson Comorbidity Index score ≥ 3; OR, 1.51; P < 0.001) and covered with Medicare or Medicaid versus private insurance (OR, 1.40; P < 0.001 and OR, 1.45; P < 0.001, respectively).

CONCLUSIONS

Emergency department visits for AP represent a significant burden on US health care. Although mortality is lower than previously reported, significant disparities exist in patients presenting with AP with regard to admission and mortality rates. Further investigations are needed to assess these disparities.

A population-based evaluation of readmissions after first hospitalization for acute pancreatitis

OBJECTIVE

This study aimed to evaluate the burden and pattern of pancreatitis-related readmissions after index hospitalization for acute pancreatitis (AP).

METHODS

We identified all unique white or black Allegheny County residents with first hospital admission for AP from 1996 to 2005 using the Pennsylvania Health Care Cost Containment Council data set. The final study population consisted of patients (n = 6010) who survived index admission and had follow-up data on readmissions. The etiology was determined using associated diagnosis codes. We analyzed pancreatitis-related readmissions until the third quarter of 2007 (median follow-up time, 39 months).

RESULTS

The absolute risk and total burden of readmissions were 21.9% and 2947 for primary AP, respectively, 5.8% and 812 for primary chronic pancreatitis (CP), respectively, and 32.3% and 6612 for any pancreatitis diagnosis, respectively. Patients with alcohol etiology (etiology on index admission in 20.3%; responsible for 41.6%-50.4% readmissions) and subsequent diagnosis of CP (any CP diagnosis, 12.8%; responsible for 73% readmissions) accounted for a disproportionately higher fraction of readmissions. Readmission risk decreased with increasing age. A small fraction of patients accounted for most readmissions.

CONCLUSIONS

Readmission after AP is influenced by demographics, etiology, and subsequent CP diagnosis. Future studies should focus on understanding the factors driving readmissions in high-risk individuals to develop strategies for reducing pancreatitis-related readmissions and health care costs.

Portosplenomesenteric venous thrombosis in patients with acute pancreatitis is associated with pancreatic necrosis and usually has a benign course

BACKGROUND & AIMS

Although there are some data on prevalence of portosplenomesenteric venous thrombosis (PSMVT) in patients with acute pancreatitis (AP), the progression of PSMVT in patients who have and have not received anticoagulants has not been studied systematically. We evaluated the prevalence and natural history of PSMVT in a well-defined cohort of individuals with AP.

METHODS

In a retrospective study, we analyzed data from the University of Pittsburgh Medical Center on 162 patients with a sentinel attack of AP from 2003-2010. Data were collected on patient demographics, clinical presentation, etiology, clinical course, and outcomes. One hundred twenty-two patients underwent contrast-enhanced computed tomography; the scans were reviewed to identify thromboses and/or narrowing of splanchnic veins (splenic, superior mesenteric, and portal).

RESULTS

PSMVT was detected in 22 patients overall (14%; 18% among patients who underwent contrast-enhanced computed tomography). Median time to detection of PSMVT was 17 days (interquartile range, 11-40 days). PSMVT formed most frequently in the splenic vein (19 of 22, 86%), followed by portal (8 of 22, 36%) and superior mesenteric (6/22, 27%) veins. Development of PSMVT was associated with presence (21 of 22, 95%), location, and extent of pancreatic necrosis. Fifty-three percent of patients (21 of 40) with necrosis developed PSMVT. Anticoagulants were administered infrequently (6 of 22, 27%) and always for indications unrelated to PSMVT. Most patients with PSMVT developed collateral veins (19 of 22, 86%), and 27% (6 of 22) were found to have varices during endoscopic evaluation, but clot resolution was infrequent (2 of 22, 9%). No patient developed complications directly related to PSMVT.

CONCLUSIONS

PSMVT develops in about half of patients with necrotizing AP and is rare in the absence of necrosis. Despite infrequent administration of anticoagulants, complications directly related to PSMVT are rare.

Issues in hypertriglyceridemic pancreatitis: an update

Hypertriglyceridemia (HTG) is a well-established but underestimated cause of acute pancreatitis and recurrent acute pancreatitis. The clinical presentation of HTG-induced pancreatitis (HTG pancreatitis) is similar to other causes. Pancreatitis secondary to HTG is typically seen in the presence of one or more secondary factors (uncontrolled diabetes, alcoholism, medications, pregnancy) in a patient with an underlying common genetic abnormality of lipoprotein metabolism (familial combined hyperlipidemia or familial HTG). Less commonly, a patient with rare genetic abnormality (familial chylomicronemic syndrome) with or without an additional secondary factor is encountered. The risk of acute pancreatitis in patients with serum triglycerides >1000 and >2000 mg/dL is ∼ 5% and 10% to 20%, respectively. It is not clear whether HTG pancreatitis is more severe than when it is due to other causes. Clinical management of HTG pancreatitis is similar to that of other causes. Insulin infusion in diabetic patients with HTG can rapidly reduce triglyceride (TG) levels. Use of apheresis is still experimental and better designed studies are needed to clarify its role in the management of HTG pancreatitis. Diet, lifestyle changes, and control of secondary factors are key to the treatment, and medications are useful adjuncts to the long-term management of TG levels. Control of TG levels to 500 mg/dL or less can effectively prevent recurrences of pancreatitis.

Pitfalls of using administrative data sets to describe clinical outcomes in sickle cell disease

BACKGROUND

Administrative data sets are increasingly being used to describe clinical care in sickle cell disease (SCD). We recently used such an administrative database to look at the frequency of acute chest syndrome (ACS) and the use of transfusion to treat this syndrome in California patients from 2005 to 2010. Our results revealed a surprisingly low rate of transfusion for this life-threatening situation.

PROCEDURE

To validate these results, we compared California OSPHD (Office of Statewide Health Planning and Development) administrative data with medical record review of patients diagnosed with ACS identified by two pediatric and one adult hospital databases during 2009-2010.

RESULTS

ACS or a related pulmonary process accounted for one-fifth of the inpatient hospital discharges associated with the diagnosis of SCD between 2005 and 2010. Only 47% of those discharges were associated with a transfusion. However, chart reviews found that hospital databases over-reported visits for ACS. OSHPD underreported transfusions compared to hospital data. The net effect was a markedly higher true rate of transfusion (40.7% vs. 70.2%).

CONCLUSIONS

These results point out the difficulties in using this administrative data base to describe clinical care for ACS given the variation in clinician recognition of this entity. OSPHD is widely used to inform health care policy in California and contributes to national databases. Our study suggests that using this administrative database to assess clinical care for SCD may lead to inaccurate assumptions about quality of care for SCD patients in California. Future studies on health services in SCD may require a different methodology.

A population-based study of severity in patients with acute on chronic pancreatitis

OBJECTIVES

The objectives of this study were to evaluate the severity of patients with acute pancreatitis (AP) on chronic pancreatitis (CP) and compare this to patients with AP without CP.

METHODS

The Maryland Health Services database was queried for all adult inpatient discharges with a primary diagnosis of AP from 1994 to 2010. Acute pancreatitis on CP and AP without CP were defined by the presence of the associated diagnosis code for CP. Severity was defined as organ failure, intensive care unit stay, or mortality.

RESULTS

Acute pancreatitis on CP accounted for 13.7% of all AP discharges (9747/70,944). The proportion of AP-on-CP discharges doubled during the study period (8.8% to 17.6%; P < 0.0001). When compared with patients with AP without CP, AP-on-CP patients were younger, were more likely to be male and black, had higher rates of alcohol and drug abuse, and had less severe disease with lower rates of mortality, organ failure, need for mechanical ventilation, and intensive care unit stay. Among AP-on-CP patients, significant predictors of severity included advanced age, weight loss, and 2 or more comorbidities.

CONCLUSIONS

Patients with AP on CP have less severe disease than do those with AP without CP. Weight loss, advanced age, and comorbidity increase the risk of severity in patients with AP on CP.

The epidemiology of pancreatitis and pancreatic cancer

Acute pancreatitis is one of the most frequent gastrointestinal causes of hospital admission in the United States. Chronic pancreatitis, although lower in incidence, significantly reduces patients' quality of life. Pancreatic cancer is associated with a high mortality rate and is one of the top 5 causes of death from cancer. The burden of pancreatic disorders is expected to increase over time. The risk and etiology of pancreatitis differ with age and sex, and all pancreatic disorders affect the black population more than any other race. Gallstones are the most common cause of acute pancreatitis, and early cholecystectomy eliminates the risk of future attacks. Alcohol continues to be the single most important risk factor for chronic pancreatitis. Smoking is an independent risk factor for acute and chronic pancreatitis, and its effects could synergize with those of alcohol. Significant risk factors for pancreatic cancer include smoking and non-O blood groups. Alcohol abstinence and smoking cessation can alter the progression of pancreatitis and reduce recurrence; smoking cessation is the most effective strategy to reduce the risk of pancreatic cancer.