Mo1334

Validation and Comparison of the New Severity Classification Systems WithOld Atlanta Classification for Severity of Acute PancreatitisRagesh B. Thandassery, Manish Manrai, Pradeep K. Siddappa, Jahangeer B. Medarapalem,Sreekanth Appasani, Saroj K. Sinha, Manik Sharma, Thakur D. Yadav, Rakesh Kochhar

Background Two new classification systems for the severity of acute pancreatitis (AP) havebeen proposed recently, the determinant based classification (DBC) and revised Atlantaclassification (RAC). We aimed to validate and compare these classification systems withoriginal Atlanta classification (OAC). Aims To validate and compare the DBC and RAC withoriginal Atlanta classification (OAC) Methods 469 adult patients with AP admitted to atertiary care center from January 2009-June 2013 were included in the study. The newclassification systems were validated and compared in terms of outcomes (need for interven-tions, total hospital and intensive care unit (ICU) stay and mortality). Results The mean ageof patients was 39.9±13.4 years (331 males) with the commonest etiology being alcohol(161, 34.3%) followed by gall stones (125, 26.6%). There were 119 (25.4%) patients withmild and 250 (74.6%) patients with severe AP as per OAC. Pancreatic necrosis was presentin 66.1% and infected pancreatic necrosis in 23.1% patients. 126 (26.9%) patients underwentinterventions (endoscopic n= 49, 10.4%, radiological n=95, 20.2% and surgical n=47, 10%).93 (19.8%) patients died. As per DBC, 97(20.7%), 172 (36.7%), 152 (32.4%), and 48(10.2%)patients were determined to have mild, moderate, severe, and critical AP, respectively. Asper RAC, 119 (25.4%), 160 (34.1%), and 190 patients (40.3%) were determined to havemild, moderately severe, and severe AP, respectively. Higher grades of severity were associatedwith worse outcomes in DBC, RAC and OAC. Predictive accuracies were evaluated usingarea under the receiver operator characteristics curve (AUROC) and Somer's D co-efficient.The DBC, RAC and OAC were comparable in predicting the need for interventions (AUROC0.53, 0.55, 0.54, p=0.36) and length of hospital stay (Somer's D, 0.27, 0.26, 0.23, p=0.41).However, both DBC and RAC had comparable but better accuracy than OAC in predictingneed for ICU admission (AUROC 0.73 for both vs. 0.62 for OAC, P<0.001), length of ICUstay (Somer's D, 0.35 for both vs. 0.24 for OAC, p<0.001) and mortality (AUROC 0.78 forboth vs. 0.61 for OAC, p<0.001). Conclusion Determinant based classification and revisedAtlanta classification categorize patients into subgroups that reflect clinical outcomes. Bothhave comparable and higher predictive accuracy than old Atlanta classification for need forICU admission, length of ICU stay and mortality.

Mo1335

Systemic Inflammatory Response Syndrome (SIRS) in Acute Pancreatitis (AP):Outcome of Early Fluid TherapyMahya Faghih, Elham Afghani, Amitasha Sinha, Mouen Khashab, Joanna K. Law, AnneMarie Lennon, Enrique de-Madaria, Vikesh K. Singh

Background: SIRS is common among AP patients presenting to ED. Fluid therapy has beenassociated with a reduction in SIRS. Aims: To evaluate the effect of fluid therapy among APpatients with SIRS in ED & SIRS within 24 hrs on medical ward (MW). Methods: Demo-graphic, clinical, & laboratory data was collected on all adult AP patients admitted to medicalward (MW) from ED between 1/10-1/13 in the first 7 days of admission. Exclusion criteriaincluded: no SIRS in ED, outside hospital transfers, prolonged ED course (>24 hrs), currenthemodialysis, >2 previous episodes of AP, incomplete data, & underlying chronic pancreatitis(presence of calcification and/or main pancreatic duct ≥ 5 mm). Comorbidity was assessedusing Charlson comorbidity index (CCI). The fluid administered in ED was compared inpatients with & without SIRS on admission to MW. We also evaluated fluid administeredwithin initial 24 hrs of presentation to MW & outcomes in patients who developed persistentSIRS (>48 hrs) in MW. Persistent organ failure (POF), acute fluid collections (AFC) &pancreatic necrosis were defined using the revised Atlanta classification. We also evaluatedlength of stay (LOS), need for nutritional support, need for invasive treatments, ICU stay, &mortality. Results: A total of 199 AP patients presented to ED, of whom 76 (38.2%) metinclusion criteria, (60.5% males, mean age of 47 ± 13.9 years, median CCI of 1 [0,2], &alcoholic etiology in 63.2%). Mean time spent in ED was 10.9 ± 4.8 hrs & mean durationof symptoms prior to presentation was 3.8 ± 4.9 days. Of these, 44 (57.9%) continued tohave SIRS within 24 hrs of admission to MW while 32(42.1%) had resolution of SIRS. Therewere no significant differences between the two groups in terms of etiology, CCI, time spentin ED, duration of symptoms prior to presentation, BUN, hematocrit (HCT), & creatinine(Cr). There was no significant difference between total fluids administered in ED betweenthose who continued to have SIRS as compared to those who had resolution of SIRS inMW (2.8 ± 1.6 L vs. 2.4 ± 1.3 L, p= 0.08). Of the 44, 20(45.4%) developed persistentSIRS. There were no significant differences between those with persistent SIRS & those whodid not develop persistent SIRS (n=24) with regards to BUN, Cr, HCT, total fluids receivedin 24 hours on MW (p>0.05). The 20 patients who developed persistent SIRS had significantlymore need for nutritional support (20% vs. 0%, p= 0.02), AFC (50% vs. 12.5%, p=0.007),

S-623 AGA Abstracts

POF (20% vs. 0%, p=0.02), and longer LOS (20.5 ± 35.7 vs. 3.9 ± 2.36, p=0.03) whencompared to the 24 patients who did not have persistent SIRS. Conclusion: SIRS that doesnot resolve by the time of hospital admission in AP is associated with a nearly 50% risk ofdeveloping persistent SIRS & these patients are at risk for poor outcomes. Early fluidadministration did not attenuate SIRS in this cohort.

Mo1336

Early Predictors and Outcomes of Increased Fluid Sequestration in AcutePancreatitisMahya Faghih, Elham Afghani, Amitasha Sinha, Joanna K. Law, Mouen Khashab, AnneMarie Lennon, Enrique de-Madaria, Vikesh K. Singh

Background: Clinical guidelines recommend early and aggressive fluid therapy in patientswith acute pancreatitis (AP). However prospective studies in humans have suggested thatthis may be detrimental due to fluid sequestration (FS). Identifying early predictors ofincreased FS might allow for the individualization of fluid therapy. Aims: To evaluateadmission predictors associated with increased FS in the first 48 hours in patients with AP.Methods: Demographic, clinical, and laboratory data of all consecutive adults (age≥18 years)admitted with a diagnosis of AP from Jan 2010 to Jan 2013 was collected. AP was definedas 2 of the 3 criteria: characteristic abdominal pain, amylase/lipase levels >3X the upperlimit of normal; and/or CT imaging consistent with AP. FS was calculated by subtractingthe total amount of fluid output from input in the first 48 hours of presentation (FS 48h).Fluid output also included insensible losses (10mL/g of body weight) and temperature >37.8C (500 mL extra fluid output/ day). Patients on hemodialysis, >2 previous episodes of AP,transfers from outside hospitals, incomplete data, underlying chronic pancreatitis (CP) asdefined by the presence of calcification and/or dilated main pancreatic duct (≥ 5 mm) onpast or current imaging were excluded. Comorbidity was quantified using the age-adjustedCharlson index (ACCI). BISAP was defined by BUN>25, impaired mental status, systemicinflammatory response syndrome (SIRS), age>60, and pleural effusions. Outcomes assessedincluded length of hospital stay, acute fluid collection(s) (AFC), pancreatic necrosis (PN),persistent organ failure (POF), and mortality. AFC, PN, and POF were defined in accordancewith the revised Atlanta classification Results: There were 354 patients with AP, of whom214 (60.5%) met the inclusion criteria (53.3% male, mean age of 47.8 ± 15.0 yrs, medianACCI of 2 [0,2], median BISAP of 1 [0,1], alcohol etiology 53.3%, median FS 48h 4.3 L[2.5, 6.1]). 3.2% of patients in the cohort developed pancreatic necrosis. Both simple andmultiple linear regression analysis showed that age<40 (p<0.005), alcohol etiology (p<0.001),and SIRS (p<0.001) on admission were significantly associated with increased FS 48h.Admission hematocrit, glucose, creatinine, and BUN were not associated with increased FS48h (p>0.05). Increased FS was significantly associated with persistent SIRS (p<0.001), POF(p<0.001), and ICU stay (p=0.008). Conclusion: Young age, alcohol etiology, and SIRS areearly and independent predictors of increased FS 48h in patients with AP. Hemoconcentrationwas not significantly associated with increased FS in this cohort due to the small numberof patients with PN. Increased FS 48 h is associated with poor outcomes.

Mo1337

Risk Factors for the Development of Intra-Abdominal Fungal Infections inAcute PancreatitisTimothy B. Gardner, Stuart R. Gordon

Background & Aims: Intra-abdominal pancreatic fungal infections (PFI) complicating acutepancreatitis arise proportionally to the extent of pancreatic necrosis, although risk factorsfor the development of PFI are not well characterized. We aimed to determine risk factorswhich contributed to PFI in patients with acute pancreatitis. Methods: Records were reviewedfrom a large single center database of 479 non-transferred patients with acute pancreatitisadmitted to our medical center from 1985-2009. Demographic, procedural, and outcomesdata were abstracted with the primary outcome being the presence of a culture-confirmedpancreatic fungal infection. Results: Out of 479 patients admitted to our medical center foracute pancreatitis, 17 were subsequently found to have an intra-abdominal fungal infectionand 3 of these patients died. The median length of stay for patients with PFI was 24 daysand 77% were admitted to the intensive care unit. C. albicans was the most frequentlyencountered organism, followed by C. tropicalis and C. krusei. Patients with intra-abdominalfungal infections were more likely to have received prophylactic admission antibiotics (OR1.7, 95% C.I. 1.2-2.3), TPN within 7 days of admission (OR 1.4, 95% C.I. 1.1-1.7), andto have necrosis on CT scan within 7 days of admission (OR 1.4, 95% C.I. 1.1-1.7). Thedegree of necrosis (<50% vs. >50% glandular necrosis) was not more predictive of risk.Aggressive fluid resuscitation (greater than 1/3 of 72 hour IV fluids given within the first24 hours - OR 0.9, 95% C.I. 0.7-1.3), age >60 years, gender were not protective againstthe development of PFI. Multivariable regression identified admission antibiotic use (OR1.6, 95% C.I. 1.4-1.8) as the strongest predictor for PFI. Conclusion: Although rare, pan-creatic fungal infections are a source of considerable morbidity and mortality. Because theprophylactic use of admission antibiotics is the best predictor for the development of PFI,they should be avoided in patients with acute pancreatitis.

Mo1338

Comparative Evaluation of Abdominal Ultrasound, Endoscopic Ultrasound andMagnetic Resonance Imaging in Detecting Solid Necrotic Debris in Walled offPancreatic NecrosisVinita Chaudhary, Ravi Sharma, Surinder S. Rana, Vishal Sharma, Puneet Chhabra,Deepak K. Bhasin

Introduction: Walled off pancreatic necrosis (WON) is an important complication of acutenecrotising pancreatitis which is usually diagnosed using investigations like endoscopicultrasound (EUS)/ magnetic resonance imaging (MRI) that can visualize the necrotic debrisbetter. However, these investigations are expensive and not widely available. The role ofabdominal ultrasound, an inexpensive and widely available investigation, in WOPN is not

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