P-BN07 Identifying gallstones in acute pancreatitis. Are we undermanaging our patients?

Abstract Background Acute pancreatitis (AP) is a common surgical presentation with a wide spectrum of severity and outcome. The most common cause of AP is gallstones, accounting for approximately 50% of cases, followed by alcohol excess. Reliable identification of gallstones is crucial as patients can be offered cholecystectomy to prevent recurrence. Current UK guidelines recommend a minimum of two negative ultrasounds to rule out gallstones. The aim of this study was to assess the pickup rate of gallstones on ultrasound for patients admitted with AP and audit our compliance with UK guidelines. Methods All patients admitted with acute pancreatitis between the start of January 2019 to the end of December 2020 were retrospectively analysed. All patients with a known pre-existing cause for pancreatitis such as alcohol excess, chronic pancreatitis, CBD stricture and pancreatic mass were excluded. Electronic records were examined to identify subsequent imaging investigations and final diagnosis. Particular interest was given to whether gallstones were identified, and adherence to UK guidelines. Results 206 patients were identified following the exclusion criteria. 189 underwent an ultrasound on admission, 111 were positive for gallstones. Of the negative ultrasounds (78), 15 underwent a further USS (4 positive), 29 underwent an MRCP (12 positive), 15 had a CT (3 positive) and 3 had an ERCP (3 positive). This left 16 with an unknown aetiology after 1 ultrasound and did not undergo further imaging and therefore did not comply with the current guidelines. Of the 11 patients who had 2 negative ultrasounds 5 had further imaging and all were negative for gallstones. Conclusions In conclusion Gallstone pancreatitis is a common acute surgical presentation of which morbidity and mortality can be significant. Following our retrospective assessment, we deem secondary imaging in the form of USS or MRCP to be necessary in the investigation of acute pancreatitis due to the high pickup rate. Compliance with current guidelines aids diagnostics and ensures appropriate and timely management of this condition leading to improved patient care.

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The association of triglyceride levels with the incidence of initial and recurrent acute pancreatitis

Lipids in Health and Disease ◽

10.1186/s12944-021-01488-8 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

Robert J. Sanchez ◽

Wenzhen Ge ◽

Wenhui Wei ◽

Manish P. Ponda ◽

Robert S. Rosenson

Keyword(s):

Acute Pancreatitis ◽

Medical Records ◽

Adult Population ◽

Baseline Period ◽

Prior History ◽

Inclusion Criteria ◽

Exclusion Criteria ◽

Recurrent Acute Pancreatitis ◽

History Of ◽

Nationally Representative

Abstract Background This retrospective cohort study assessed the annualized incidence rate (IR) of acute pancreatitis (AP) in a nationally representative US adult population, as well as the variation in the risk of AP events across strata of triglyceride (TG) levels. Methods Data were obtained from IQVIA’s US Ambulatory Electronic Medical Records (EMR) database linked with its LRxDx Open Claims database. Inclusion criteria included ≥1 serum TG value during the overlapping study period of the EMR and claims databases, ≥1 claim in the 12-month baseline period, and ≥ 1 claim in the 12 months post index. All TG measurements were assigned to the highest category reached: < 2.26, ≥2.26 to ≤5.65, > 5.65 to ≤9.94, > 9.94, and > 11.29 mmol/L (< 200, ≥200 to ≤500, > 500 to ≤880, > 880, and > 1000 mg/dL, respectively). The outcome of interest was AP, defined as a hospitalization event with AP as the principal diagnosis. Results In total, 7,119,195 patients met the inclusion/exclusion criteria, of whom 4158 (0.058%) had ≥1 AP events in the prior 12 months. Most patients (83%) had TGs < 2.26 mmol/L (< 200 mg/dL), while < 1% had TGs > 9.94 mmol/L (> 880 mg/dL). Overall, the IR of AP was low (0.08%; 95% confidence internal [CI], 0.08–0.08%), but increased with increasing TGs (0.08% in TGs < 2.26 mmol/L [< 200 mg/dL] to 1.21% in TGs > 11.29 mmol/L [> 1000 mg/dL]). In patients with a prior history of AP, the IR of AP increased dramatically; patients with ≥2 AP events at baseline had an IR of 29.98% (95% CI, 25.1–34.9%). Conclusion The risk of AP increases with increasing TG strata; however, the risk increases dramatically among patients with a recent history of AP.

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Adding stress biomarkers to high sensitivity troponin measurements increases precision and efficacy of rapid rule out protocols for NSTEMI

European Heart Journal ◽

10.1093/ehjci/ehaa946.1698 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

I Restan ◽

O.T Steiro ◽

H.L Tjora ◽

J Langoergen ◽

T Omland ◽

...

Keyword(s):

Chest Pain ◽

Acute Chest Pain ◽

High Sensitivity ◽

Final Diagnosis ◽

Public Institution ◽

P Value ◽

Funding Source ◽

University Hospitals ◽

High Sensitivity Troponin ◽

Rule Out

Abstract Background NSTEMI may be ruled out in patients presenting with acute chest pain based on low baseline high sensitivity troponin (cTn) at admission. This procedure is limited by a low expected frequency of ruled out non-cardiac chest pain (NCCP) patients. Purpose To investigate if stress-induced biomarkers (glucose or copeptin) combined with cTn can increase the rate of NCCP ruled out without an unacceptable increase in incorrectly ruled out NSTEMI. Method 971 patients with suspected NSTE-ACS were included. Final diagnosis was adjudicated by two independent cardiologists using clinical data including routine cTnT. Additionally, baseline cTnI, cTnI from Singulex Clarity System (cTnI(sgx)), copeptin and glucose were measured. Diagnostic performance to rule out NSTEMI was compared between the ESC rule out algorithms for cTnT and cTnI(Abbott), a local cTnI(sgx) algorithm and different combinations of cTn with copeptin or glucose Results Median age 61 years, 60% male. 13% had NSTEMI, 12% had UAP and 60% NCCP. Distribution of copeptin and glucose concentrations (NSTEMI and NCCP) is shown in figure 1. Copeptin and cTnT produces an algorithm with lower miss rate for NSTEMI, increased rule out rate for NCCP and significantly higher AUC (DeLong test, p value <0.001) compared to the ESC algorithm (Table 1). cTnI(sgx) and copeptin showed higher rule out for NCCP and higher AUC (p value <0.001), however an increased rule out rate for NSTEMIs. Combining cTnI(Abbott) and glucose gave a similar miss rate for NSTEMI as ESC, but increased rule out rate for NCCP and higher AUC (p value <0.001). Conclusion Combining cTnT or cTnI(sgx) with copeptin; or cTnI with glucose, improves diagnostic precision and efficacy of rule out protocols for NSTEMI in patients presenting with acute chest pain. Figure 1 Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Western Norway Regional Health Authority; Haukeland and Stavanger University Hospitals

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International management platform for children’s interstitial lung disease (chILD-EU)

Thorax ◽

10.1136/thoraxjnl-2017-210519 ◽

2017 ◽

Vol 73 (3) ◽

pp. 231-239 ◽

Cited By ~ 23

Author(s):

Matthias Griese ◽

Elias Seidl ◽

Meike Hengst ◽

Simone Reu ◽

Hans Rock ◽

...

Keyword(s):

Wide Spectrum ◽

Final Diagnosis ◽

Interstitial Lung Diseases ◽

International Management ◽

Significant Information ◽

Web Based ◽

Management Platform ◽

Long Term Follow Up ◽

Registration Number

BackgroundChildren’s interstitial lung diseases (chILD) cover many rare entities, frequently not diagnosed or studied in detail. There is a great need for specialised advice and for internationally agreed subclassification of entities collected in a register.Our objective was to implement an international management platform with independent multidisciplinary review of cases at presentation for long-term follow-up and to test if this would allow for more accurate diagnosis. Also, quality and reproducibility of a diagnostic subclassification system were assessed using a collection of 25 complex chILD cases.MethodsA web-based chILD management platform with a registry and biobank was successfully designed and implemented.ResultsOver a 3-year period, 575 patients were included for observation spanning a wide spectrum of chILD. In 346 patients, multidisciplinary reviews were completed by teams at five international sites (Munich 51%, London 12%, Hannover 31%, Ankara 1% and Paris 5%). In 13%, the diagnosis reached by the referring team was not confirmed by peer review. Among these, the diagnosis initially given was wrong (27%), imprecise (50%) or significant information was added (23%).The ability of nine expert clinicians to subcategorise the final diagnosis into the chILD-EU register classification had an overall exact inter-rater agreement of 59% on first assessment and after training, 64%. Only 10% of the ‘wrong’ answers resulted in allocation to an incorrect category. Subcategorisation proved useful but training is needed for optimal implementation.ConclusionsWe have shown that chILD-EU has generated a platform to help the clinical assessment of chILD.Trial registration numberResults, NCT02852928.

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Solitary Plasmacytoma in the Mandible Resembling an Odontogenic Cyst/Tumor

Case Reports in Dentistry ◽

10.1155/2016/3629047 ◽

2016 ◽

Vol 2016 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Fatemeh Rezaei ◽

Hesamedin Nazari ◽

Babak Izadi

Keyword(s):

Multiple Myeloma ◽

Third Molar ◽

Panoramic Radiograph ◽

Final Diagnosis ◽

Chief Complaint ◽

Solitary Plasmacytoma ◽

Oral Medicine ◽

Bony Lesion ◽

The Right ◽

Rule Out

A 46-year-old male patient referred to Department of Oral Medicine, with the primary chief complaint of a painless swelling in the right side of mandibular. A panoramic radiograph revealed a well-defined, multilocular radiolucent bony lesion with thin and straight septa in the right side of mandible extending from distal of canine to mesial of third molar. Histological examination showed a solid proliferation of atypical plasmacytoid cells, which was indicative of plasmacytoma. A systemic workup for the final diagnosis was performed to rule out multiple myeloma.

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Bacterial Co-infections in HIV/AIDS-positive Subjects: A Systematic Review and Meta-analysis

Folia Medica ◽

10.2478/folmed-2018-0007 ◽

2018 ◽

Vol 60 (3) ◽

pp. 339-350 ◽

Cited By ~ 2

Author(s):

Farzad Khademi ◽

Arshid Yousefi-Avarvand ◽

Amirhossein Sahebkar ◽

Fahimeh Ghanbari ◽

Hamid Vaez

Keyword(s):

Bacterial Infections ◽

Wide Spectrum ◽

Meta Analysis ◽

Exclusion Criteria ◽

Sexually Transmitted ◽

Related Data ◽

Preventive Methods ◽

Timely Treatment ◽

Data Banks ◽

Hiv Aids

Abstract Background: Bacterial infections are the most common complications in people with HIV/AIDS. There has been no previous report on the prevalence of bacterial co-infections in Iranian HIV/AIDS-positive subjects. Aim: To evaluate the frequency of bacterial infections in hospitalized HIV/AIDS-infected patients in Iran. Materials and methods: Based on PRISMA guidelines, a computerized search in related data banks using relevant keywords was performed in both Persian and English languages for articles that were published until March 10, 2017. A total of 1118 original articles were systematically reviewed to identify eligible studies on the prevalence of bacterial co-infections in HIV/AIDS-infected patients from Iran. After screening for inclusion and exclusion criteria, we extracted data from 28 eligible articles for the meta-analysis. Results: The overall bacterial infection rate among Iranian HIV/AIDS-positive individuals was estimated to be 48.6%. Gastrointestinal disorders (59.5%) were the most frequent bacterial infections in this group of patients followed by bacterial lymphadenopathy (38.9%), TB infection (38.2%), bacterial pneumonia (31.2%), brucellosis (26.3%), skin infections (13.3%) and sexually transmitted infections (9.7%). The prevalence of other bacterial infections including endocarditis, sepsis and Staphylococcus aureus (S. aureus) were 10%, 9.1%, and 6.9%, respectively. Conclusion: The prevalence of a wide spectrum of bacterial co-infections, especially endemic infections, in Iranian HIV/AIDS-infected patients, is alarming and calls for urgent need to improve the currently applied diagnostic and preventive methods. In addition, timely treatment of these infections is pivotal to decrease the morbidity and mortality rates in HIV/AIDS-infected patients.

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Management of acute pancreatitis in the critically ill

10.1093/med/9780199600830.003.0191 ◽

2016 ◽

Author(s):

Rajkumar Rajendram

Keyword(s):

Acute Pancreatitis ◽

Enteral Nutrition ◽

Parenteral Nutrition ◽

Severe Acute Pancreatitis ◽

Specific Treatment ◽

Morbidity And Mortality ◽

Surgical Removal ◽

Gallstone Pancreatitis ◽

Nasogastric Feeding ◽

Open Necrosectomy

The major causes of morbidity and mortality in acute pancreatitis are organ dysfunction and infection of necrotic tissue. Management should aim to prevent, or to diagnose and treat, the complications of pancreatic inflammation, and any predisposing factors to avoid recurrence. Medical management is essentially supportive with oxygen, intravenous fluids, analgesia, enteral or parenteral nutrition, and correction of metabolic abnormalities. Patients with severe acute pancreatitis are unlikely to resume prompt oral intake so nutritional support is also required. Post-pyloric feeding is not required if nasogastric feeding is tolerated. However, enteral nutrition, whether oral, gastric, or post-pyloric, can cause pain, recurrence of pancreatitis or an increase in fluid collections, so parenteral nutrition may be necessary. The necrotic pancreas becomes infected in a third of patients with severe acute pancreatitis. Treatment of infection includes systemic antimicrobials, enteral nutrition, percutaneous aspiration, and necrosectomy. However, compared with open necrosectomy, a minimally invasive step-up approach consisting of percutaneous drainage followed, if necessary, by open necrosectomy, reduces morbidity and mortality. The aetiology of the pancreatitis must also be treated to prevent recurrence and the complications of pancreatic failure. Gallstones are the most common cause of pancreatitis that requires specific treatment. Endoscopic or surgical removal of stones may reduce the severity of pancreatitis. Patients should also have cholecystectomy after recovery from gallstone pancreatitis. Effective management of acute pancreatitis requires multidisciplinary engagement. The mainstay of management involves supportive prevention and treatment of complications, infection, and organ failure to avoid or delay surgery.

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New Predictor of Organ Failure in Acute Pancreatitis: CD4+ T Lymphocytes and CD19+ B Lymphocytes

BioMed Research International ◽

10.1155/2018/1012584 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 1

Author(s):

Chenyuan Shi ◽

Chaoqun Hou ◽

Xiaole Zhu ◽

Yunpeng Peng ◽

Feng Guo ◽

...

Keyword(s):

Acute Pancreatitis ◽

T Lymphocytes ◽

Organ Failure ◽

Clinical Outcomes ◽

B Lymphocytes ◽

T Lymphocyte ◽

Roc Curve ◽

Scoring Systems ◽

Gallstone Pancreatitis ◽

Effector Cells

Objective. Lymphocytes are one of the main effector cells in the inflammatory response of acute pancreatitis (AP). The purpose of the study was to evaluate whether peripheral blood lymphocyte (PBL) subsets at admission change during AP based on clinical outcomes and to explore whether these changes vary by aetiology of AP. Hence, we performed a prospective study to find a predictor in lymphocyte subsets that might allow easier, earlier, and more accurate prediction of clinical outcomes. Methods. Patients with AP were enrolled from December 2017 to June 2018 at the First Affiliated Hospital of Nanjing Medical University. Age, sex, clinical and biochemical parameters, and aetiology of AP were obtained at admission. PBL counts were assessed within 24 hours after admission. Clinical outcomes were observed as endpoints. The areas under the curve (AUCs) of different predictors were calculated using the receiver operating characteristic (ROC) curve. Results. Overall, 133 patients were included. Patients (n=24) with organ failure (OF) had significantly lower CD4+ T lymphocyte levels than those (n=109) with No OF (NOF) (39.60 (33.94-46.13) vs. 32.41 (26.51-38.00), P=0.004). The OF group exhibited significantly higher CD19+ B lymphocytes than the NOF group (16.07 (10.67-21.06) vs. 23.78 (17.84-29.45), P=0.001). Of the AP cases, 68.8% were caused by gallstones; 10.1% were attributed to alcohol; 16.5% were due to hyperlipidaemia; and 4.6% had other causes. Across all aetiologies, a lower CD4+ T lymphocyte level was significantly related to OF (P<0.05). However, CD19+ B lymphocytes were significant only in gallstone pancreatitis (P<0.05). The ROC curve results showed that the AUC values of CD4+T lymphocytes, CD19+ B lymphocytes, and combined CD4+T lymphocytes and CD19+ B lymphocytes were similar to those of traditional scoring systems, such as APACHEII and Ranson. Conclusions. CD4+ T and CD19+ B lymphocytes during the early phase of AP can predict OF.

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Idiopathic macrocheilia

BMJ Case Reports ◽

10.1136/bcr-2018-225682 ◽

2018 ◽

pp. bcr-2018-225682

Author(s):

Haren Pandya ◽

Hiren Dharmendrabhai Patel ◽

Jigar Mayankbhai Purani ◽

VIvek Ramesh Rayththa

Keyword(s):

Triamcinolone Acetonide ◽

Clinical Features ◽

Histopathological Examination ◽

Final Diagnosis ◽

Exclusion Criteria ◽

Gingival Enlargement

A 13-year-boy presented with painless swelling of upper and lower lips accompanied with gingival enlargement. The aetiology for these symptoms included vast pathological varieties but none of them could fit in. Clinical features were similar to orofacial graulomatosis but histopathological examination revealed chronic non-specific infection. Therefore, the final diagnosis was made as idiopathic macrocheilia through exclusion criteria. Management with intralesional triamcinolone acetonide 40 mg, twice a week for 3 weeks, resulted in significant remission in lip swelling without recurrence after a 6-month follow-up.

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1333 A Retrospective Audit Against National Standards and Guidelines of The Management and Outcomes of Acute Pancreatitis in A London District General Hospital

British Journal of Surgery ◽

10.1093/bjs/znab259.145 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

K Tytler ◽

L Nip ◽

C M Borg

Keyword(s):

Acute Pancreatitis ◽

Correct Diagnosis ◽

District General Hospital ◽

National Standards ◽

British Society ◽

Definitive Treatment ◽

Gallstone Pancreatitis ◽

Post Discharge ◽

Retrospective Audit ◽

Threatening Condition

Abstract Introduction Acute pancreatitis (AP) is a potentially life-threatening condition. The audit looks at its management and compares it versus the British Society of Gastroenterology guidelines. Method The study retrospectively assessed plans and results for patients with AP over 4 months. Targets were mortality rate below 10% (<30% for severe cases), correct diagnosis at 48h from admission, ultrasound examination of the gallbladder within 24h of diagnosis, severity stratification within 48h of diagnosis, cause established in over 80%, management involving intensive care settings for severe cases and definitive treatment of gallstone pancreatitis in less than 14 days. Results 34 patients were identified, 3(8.6%) had severe acute pancreatitis (SAP). Mortality was 2.9% overall (33.3% in SAP). AP was diagnosed within 48h of presentation in all cases with severity stratification undertaken in 91.2%. Determination of aetiology was achieved in 82.4% with the rest documented as unknown/idiopathic/requiring further investigations post-discharge. Ultrasound studies were undertaken in 58.8% of cases but, as the hospital did not offer ultrasonography on the weekend, 41.2% actually had this type of imaging performed within 24h. Within those who did not have ultrasound at 24h, 50% had had computer tomography imaging. All SAP cases were discussed with intensivists and 7.1% of gallstone pancreatitis underwent definite treatment within 2 weeks. Conclusions Current practice in the hospital mostly meets the reference standards. However, the percentage undergoing definitive treatment of gallstone pancreatitis is low. We aim to re-audit in 4 months following meetings with local surgical leads to discuss implementation of a suitable pathway.

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Mysterious Looks of Typhoid Fever: A New Experience

Bangladesh Critical Care Journal ◽

10.3329/bccj.v3i1.24104 ◽

2015 ◽

Vol 3 (1) ◽

pp. 36-38 ◽

Cited By ~ 1

Author(s):

Deepankar Kumar Basak ◽

Richmond Ronald Gomes ◽

Md Ashraf Uddin Ahmed ◽

ABM Sarwar E Alam

Keyword(s):

Acute Pancreatitis ◽

Pulmonary Hypertension ◽

Abdominal Pain ◽

Typhoid Fever ◽

Enteric Fever ◽

Wide Spectrum ◽

Case Reports ◽

Salmonella Typhi ◽

Shortness Of Breath ◽

Common Infectious Disease

Enteric fever (typhoid or paratyphoid) is a common infectious disease worldwide, especially in developing countries like Bangladesh. Typhoid fever caused by the gram negative bacterium Salmonella typhi that may have a wide spectrum of clinical presentations. We report a case of a 17 year old previously healthy college boy who presented with fever, abdominal pain and shortness of breath later on who was eventually diagnosed as having typhoid fever complicated by acute pancreatitis, hepatitis and severe pulmonary hypertension. Enteric fever presenting as acute pancreatitis and pulmonary hypertension is a rare entity and must be considered in endemic areas like Bangladesh, in patients presenting with fever and concomitant severe abdominal pain and shortness of breath, as any delay in timely institution of treatment can prove fatal. There are very few case reports in the world which have depicted this unusual association.Bangladesh Crit Care J March 2015; 3 (1): 36-38

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