Comorbidities Drive the Majority of Overall Mortality in Low-Risk Mucinous Pancreatic Cysts Under Surveillance.

BACKGROUND & AIMS: The Charlson Comorbidity Index (CACI) has been suggested as a tool to determine comorbidity burden and guide management for patients with mucinous pancreatic cysts (Intrapapillary Mucinous Neoplasms and Mucinous Cystic Neoplasms), but has not been studied well among "low-risk" mucinous pancreatic cysts i.e. without worrisome features (WF) and high-risk stigmata (HRS). This study sought to determine the comorbidity burden among surveillance population of low-risk pancreatic cysts and provide their follow-up mortality outcomes. METHODS: A single center study retrospectively reviewed a prospective pancreatic cyst database and included individuals with low-risk cysts undergoing serial imaging during 2016. Electronic medical records were reviewed to determine their baseline age-adjusted CACI (age-CACI). After 4 years, their progression to WF, disease specific (pancreatic malignancy-related, DSM), extra-pancreatic (EPM), and overall mortalities (OM) were determined using Kaplan-Meir Survival Analysis. RESULTS: 502 individuals underwent prospective surveillance. The study included 440 individuals with low-risk suspected or presumed mucinous cysts and excluded 50 and 12 individuals with WF and HRS respectively. Over a median follow-up of 56 months, 12 WF progressions, 2 DSMs, 42 EPMs, and 44 OMs were observed. Baseline age-CACI had good predictive capacity for 4-year EPM (Area-Under Curve: 0.87; p< .0001). The median age-CACI of 4 enabled cohort stratification into Low (age-CACI <4) and High CACI (age-CACI ≥4) groups. A significantly higher OM (p< .001) was observed among the High CACI group as compared to the Low CACI group. CONCLUSION: Through real-time application of CACI to patient outcomes, our analysis supports incorporation of this comorbidity assessment tool in making shared surveillance decisions among low-risk pancreatic cyst population.

Impact of endoscopic ultrasound on diagnosis and management of presumed mucinous neoplasms when done for pancreatic cyst morphology change on non-invasive surveillance imaging.

Background and study aims Guidelines for management of presumed neoplastic pancreatic cysts have encouraged noninvasive imaging for low-risk surveillance, while reserving endoscopic ultrasound for worrisome features including morphologic change. We aim to study the impact of endoscopic ultrasound on diagnosis and management compared with non-invasive imaging. Patients and methods A single-institution pancreatic cyst database was retrospectively queried for patients who underwent endoscopic ultrasound for the indication of change in cyst morphology. Diagnoses were classified as presumed mucinous neoplasm with or without worrisome features or high-risk stigmata and non-mucinous lesions. Management decisions were defined a priori as surgical evaluation for patients with high-risk stigmata, positive cytology or mural nodule, or continued surveillance for all others. Results Between January 2013 and October 2016, 709 pancreas cyst endoscopic ultrasounds were performed of which 89 were for cyst morphology change seen on noninvasive imaging including 10 presumed pseudocysts, nine presumed serous cystadenomas, and 70 presumed mucinous cystic neoplasms. Cyst morphologic changes included increase in caliber of the main pancreatic duct (7 cases), increase in cyst size (68 cases), cyst ≥ 30 mm (10 cases), and presence of a solid nodule (1 case). Median cyst size increase was 5 mm with interquartile range of 4 mm over 2.1 ±â€Š1.9 years. Endoscopic ultrasound done for morphologic change resulted in a change in diagnosis and management in 16 % and 13 % of cases, respectively. Conclusion Endoscopic ultrasound has a modest but clinically significant role in impacting diagnosis and management for presumed mucinous cystic neoplasms when performed for the indication of cyst morphology change.

Effect of a Novel Patient Garment on Perceived Privacy during Colonoscopy: A Simple Approach to Minimize Embarrassment.

BACKGROUND: In the United States, patients wear a one-piece, reusable cloth gown during colonoscopy procedures. Many patients report embarrassment related to bodily exposure during colonoscopy. This may limit participation in colorectal cancer screening programs. AIMS: To assess whether the use of a novel, disposable patient garment (Privacy Pants, Jackson, MS), which increases patient coverage, can reduce embarrassment related to bodily exposure and increase colonoscopy acceptance rates. METHODS: Patients were offered a novel gown, and they completed questionnaires before and after colonoscopy. RESULTS: A total of 120 patients participated. 54% were female and 82% were Caucasian. The novel gown had high overall satisfaction (8.3) and was associated with a sense of respect during the procedure (9.4). 67% (80) of the patients had a prior colonoscopy, and of these, 76% would request a novel gown over a traditional gown for future procedures. Among all study participants, a high rate of acceptability for repeat colonoscopy if recommended by their doctors was reported (mean of 9.4). Nonwhites were more likely to have a concern for embarrassment addressed by using novel gowns as compared to whites (P value 0.02). CONCLUSION: All participants, particularly women and nonwhite participants, reported high rates of respect and satisfaction and decrease in embarrassment utilizing the novel gown during colonoscopy. Patients who had prior colonoscopy with a traditional gown preferred the novel garment. A novel procedure gown may enhance colonoscopy acceptance by minimizing embarrassment.

Management of Autoimmune Pancreatitis.

Type 1 autoimmune pancreatitis (AIP) is an IgG-4-related systemic disease that can manifest as a pancreatic disorder or another disorder of presumed autoimmune origin. Type 2 disease is typically characterized by absent IgG-4-positive cells. As patients often present with acute pancreatitis, obstructive jaundice, or pancreatic mass, it is imperative to exclude malignancy, a more common diagnosis. AIP may respond to corticosteroids, and has a strong association with other immune-mediated diseases. Recent literature suggests the benefit of immune-modulating therapy, including rituximab, although no consensus exists. This review covers the essentials of diagnosis, but focuses primarily on management of AIP.

Hepatitis C Screening: The Downstream Dissemination of Evolving Guidelines in a Resident Continuity Clinic.

Background In 2012, the Centers for Disease Control and Prevention (CDC) published guidelines supporting one-time screening for hepatitis C (HCV) in all persons born between 1945 and 1965. It is estimated that 75% of adults infected with HCV fall within this cohort. Furthermore, it is projected that this preventative health intervention would lead to the diagnosis of 800,000 unknown cases and the prevention of 120,000 deaths. Objectives The primary objectives are to measure adherence to HCV screening in a continuity practice staffed by internal medicine residents and attending physicians and to measure the effect of educational interventions to enhance HCV screening. The secondary objectives include finding whether insurance or provider status affects adherence to HCV screening. Methods In 2015, we performed a retrospective chart review of asymptomatic patients born between 1945 and 1965 to estimate the rate of HCV screening. In order to meet inclusion criteria, the patients must have had an HCV status that was unknown and must have been seen by a primary care provider ≥ 2 times between January 1 and December 31, 2013. The data extracted included whether HCV testing was ordered, whether testing was performed primarily for screening purposes, demographic information, insurance status, number of clinic visits, and whether the primary provider was a resident or attending physician. Subsequently, in 2016 we implemented an educational intervention aimed at improving these rates. Afterwards, we repeated the chart review to determine if screening rates had improved. Results Out of 294 patients reviewed pre-intervention, 200 patients were eligible for inclusion, of which 17 (8.5%) patients were offered screening for HCV, of which 13 (76.5%) patients completed testing. Following an educational intervention, 484 patients were reviewed and 100 patients were included, of which 34 (34%) patients were screened. Compared to a pre-intervention screening rate of 8.5%, post-intervention screening had improved to 34%, a 300% increase (p<0.001). Conclusions Educational interventions are feasible and can lead to significant improvements in clinical practice enabling for the rapid dissemination of evolving guidelines.

Whipple's Disease Manifested as Recurrent Ascites.

Whipple's disease commonly presents as chronic diarrhea and abdominal pain. Ascites is an uncommon presentation of Whipple's disease. Here, we report a rare case of a 47-year-old male who presented with diarrhea and abdominal distention for three months. The physical examination was significant for ascites. Serum albumin was low and serum-to-ascites albumin gradient was < 1.1 g/dl. This suggested that ascites was less likely to be present due to portal hypertension. Enteroscopy showed erythematous duodenum and jejunum; biopsy was suggestive of periodic acid-Schiff stain (PAS) positive macrophages consistent with Whipple's disease. During the hospital course, the patient improved with intravenous (IV) ceftriaxone.

Autoimmune Pancreatitis: An Update on Diagnosis and Management.

There is an evolving understanding that autoimmune pancreatitis (AIP) is an immunoglobulin (Ig) G4 systemic disease. It can manifest as primarily a pancreatic disorder or in association with other disorders of presumed autoimmune cause. Classic clinical characteristics include obstructive jaundice, abdominal pain, and acute pancreatitis. Thus, AIP can be difficult to distinguish from pancreatic malignancy. However, AIP may respond to therapy with corticosteroids, and has a strong association with other immune mediated diseases. Although primarily a pathologic diagnosis, attempts have been made to reliably diagnose AIP clinically. AIP can be classified as either type 1 or type 2.

Zollinger-Ellison Syndrome: A Rare Case of Chronic Diarrhea.

Zollinger-Ellison syndrome (ZES) is caused by hypersecretion of gastrin from duodenal or pancreatic gastrinomas. We report a case of a 57-year-old female who presented with chronic diarrhea. CT abdomen showed multiple liver masses. Liver biopsy suggested metastatic well-differentiated neuroendocrine tumor. Serum gastrin level was markedly elevated. MRI abdomen, somatostatin receptor scintigraphy and endoscopic ultrasound failed to reveal primary site of the tumor. Upper gastrointestinal endoscopy showed hyperplastic gastric folds and multiple duodenal ulcers consistent with ZES. Patient was started on high-dose omeprazole and octreotide resulting in improvement in diarrhea.