23 - Recurrent Episode of Acute Pancreatitis in Patients With Idiopathic Acute Pancreatitis and Fatty Pancreas on Endoscopic Ultrasound

Tuesday, October 25, 2022

9:10 AM – 9:20 AM ET

Location: Hall C2

Presenting Author(s)

Pedro Cortes, MD

Mayo Clinic
Jacksonville, FL

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Pedro Cortés, MD¹, Bhaumik Brahmbhatt, MD², Massimo Raimondo, MD², Vivek Kumbhari, MD², Yan Bi, MD, PhD²
¹Mayo Clinic, Jacksonville, FL; ²Mayo Clinic Jacksonville, Jacksonville, FL

Introduction: Idiopathic acute pancreatitis (IAP) is diagnosed after a negative evaluation. It remains unclear if fatty pancreas is a cause of acute pancreatitis (AP) or a risk factor for recurrent AP. We aimed to determine if fatty pancreas was associated with a recurrent episode of AP in patients with IAP.

Methods: Patients with IAP were identified across three academic centers. Patients were included if they underwent an endoscopic ultrasound (EUS) at one of our centers. Presumed IAP prior to EUS was confirmed through retrospective review of clinical data. Patients who had an etiology discovered on EUS were excluded, leaving a cohort of “true” IAP. Presence of fatty pancreas on EUS was noted. Recurrent episode of AP, emergence of diabetes, chronic pancreatitis, and follow up cholecystectomy were recorded. Univariable analysis was performed using Wilcoxon Rank Sum or Fisher Exact tests. A Cox Proportional Hazard Regression Analysis was performed for a recurrent episode of AP.

Results: 105 patients with “true” IAP were identified. Fatty pancreas was noted in 31 patients on EUS. Older age, male gender, white race, higher BMI, obesity, presence of fatty liver, and type 2 diabetes mellitus were associated with fatty pancreas on univariable analysis. Table 1. Five patients had no follow up data after the EUS. Median time of follow up was 687 days (IQR 464-1026 days). During the follow up period, 16 patients had a recurrent episode of AP (16/100, 16%; median time to recurrence 216 days, IQR 76-420 days), 8 were diagnosed with new diabetes (8/48, 16.7%), 5 with chronic pancreatitis (5/38, 13.2%), and 10 underwent cholecystectomy (10/56, 17.9%). On unadjusted Cox regression analysis, being evaluated as a referral (p=0.0417), a history of necrotizing pancreatitis (p=0.0073), number of attacks within the preceding year before EUS (p=0.0012), and total bilirubin at the most recent episode of AP (p=0.0217) were associated with a recurrent episode of AP. Figure 1. Neither the presence of fatty pancreas nor fatty liver were significant.

Discussion: The incidence of a recurrent episode of AP was 16% over approximately 2 years in patients with IAP. The presence of fatty pancreas was not associated with a recurrent episode. Further studies on fatty pancreas in IAP are recommended.

Figure: Figure 1: Kaplan-Meier Estimates for Time to Recurrent Episode of Acute Pancreatitis. A) Entire Cohort of Patients with IAP. B) By History of Necrotizing Pancreatitis. C) By Presence of Fatty Pancreas on EUS. Legend B: Blue = History of Necrotizing Pancreatitis, Red = No History of Necrotizing Pancreatitis. Legend C: Blue = Fatty Pancreas on EUS, Red = Non-Fatty Pancreas on EUS.

Baseline Characteristics Median (IQR) or Fraction (%)		Unadjusted Univariable Analysis Median (IQR) or Fraction (%)			Unadjusted Cox Regression For Recurrent Episode AP
	All Patients N=105	No fatty pancreas N=74	Fatty pancreas N=31	p-value	HR (95% CI)	p-value
Age at EUS, per 5 years	53.8 (40.4-64.3)	47.6 (37.9-60.4)	63.7 (53.9-68.2)	< 0.001¹	0.92 (0.79-1.08)	0.3203
Male gender	45 (42.9%)	27 (36.5%)	18 (58.1%)	0.053²	1.56 (0.57-4.30)	0.3901
BMI, per 5 kg/m²	28.2 (24.2-33.7)	26.6 (22.9-29.5)	33.7 (30.4-38.8)	< 0.001¹	1.00 (0.73-1.38)	0.9769
Obesity	43 (41.0%)	17 (23.0%)	26 (83.9%)	< 0.001²	1.14 (0.41-3.15)	0.7984
White Race	96 (91.4%)	65 (87.8%)	31 (100.0%)	0.055²	0.55 (0.12-2.46)	0.4361
Hispanic Ethnicity	3 (2.9%)	2 (2.7%)	1 (3.2%)	1.000²	2.46 (0.32-18.82)	0.3859
Never Smoker	63 (60.0%)	47 (63.5%)	16 (51.6%)	0.281²	0.45 (0.16-1.27)	0.1324
Diabetes Mellitus, type 2	35 (33.3%)	20 (27.0%)	15 (48.4%)	0.043²	1.23 (0.44-3.47)	0.6890
Cholecystectomy	47 (44.8%)	34 (45.9%)	13 (41.9%)	0.830²	0.81 (0.29-2.28)	0.6947
Fatty Liver	47 (44.8%)	24 (32.4%)	23 (74.2%)	< 0.001²	0.69 (0.25-1.94)	0.4848
Evaluated as referral	74 (70.5%)	54 (73.0%)	20 (64.3%)	0.482²	0.35 (0.13-0.96)	0.0417
Necrotizing pancreatitis	11 (10.5%)	8 (10.8%)	3 (9.7%)	1.000²	4.36 (1.49-12.78)	0.0073
Single episode of AP	43 (41.0%)	30 (40.5%)	13 (41.9%)	1.000²	0.92 (0.33-2.58)	0.8712
Total attacks of AP	2 (1-3)	2 (1-3)	2 (1-3)	0.933¹	1.16 (0.96-1.40)	0.1299
Attacks within year of EUS, per 1 attack	1 (1-2)	1 (1-2)	1 (1-2)	0.349¹	1.85 (1.28-2.70)	0.0012
Fatty pancreas on EUS	31 (29.5%)	NA	NA	NA	0.74 (0.24-2.34)	0.6618
At most recent episode of AP
Lipase, per 500 U/L	920 (275-2530)	1000 (413-2500)	359 (190-3000)	0.152¹	1.01 (0.97-1.06)	0.5787
Total bilirubin, per 1 mg/dL	0.4 (0.3-0.6)	0.4 (0.3-0.6)	0.5 (0.4-0.6)	0.595¹	5.52 (1.28-23.71)	0.0217
Direct bilirubin, per 1 mg/dL	0.2 (0.2-0.2)	0.2 (0.2-0.2)	0.2 (0.2-0.2)	0.070	23.55 (0.3-1835.4)	0.1552
ALT, per 10 U/L	24 (17-35)	21 (16-33)	30 (24-39)	0.009¹	0.96 (0.79-1.17)	0.7021
Calcium, per 1 mg/dL	9.4 (9.1-9.6)	9.4 (9.1-9.7)	9.3 (9.1-9.5)	0.238¹	0.25 (0.06-1.08)	0.0626
Triglycerides, per 50 mg/dL	103 (75-173)	103 (74-158)	104 (85-177)	0.604¹	1.07 (0.83-1.36)	0.6142
IgG4 level, per 10 mg/dL	23.9 (11.1-41.0)	25.2 (11.9-40.1)	22.5 (11.3-39.7)	0.887¹	0.96 (0.76-1.21)	0.7190
CA 19-9, per 10 U/mL	8.5 (5-13)	8.5 (5.8-13.0)	7.5 (5-15)	0.712¹	0.87 (0.49-1.53)	0.6281

Table: IQR, interquartile range; AP, acute pancreatitis; HR, hazard ratio; 95% CI, 95% confidence interval; EUS, endoscopic ultrasound; BMI, body mass index; NA, not applicable; ALT, alanine transaminase; IgG4, immunoglobulin G type 4; CA 19-9, carbohydrate antigen 19-9

Reference ranges: Lipase 13 – 60 U/L, Total Bilirubin ≤ 1.2 mg/dL, Direct Bilirubin 0.0 – 0.3 mg/dL, ALT 7 – 55 U/L, Triglycerides < 150 mg/dL, Calcium 8.8 – 10.2 mg/dL, CA 19-9 < 35 U/mL, IgG4 2.4 – 121.0 mg/dL

1. Wilcoxon Rank Sum Test
2. Fisher Exact Test

Disclosures:

Pedro Cortés indicated no relevant financial relationships.

Bhaumik Brahmbhatt indicated no relevant financial relationships.

Massimo Raimondo indicated no relevant financial relationships.

Vivek Kumbhari indicated no relevant financial relationships.

Yan Bi indicated no relevant financial relationships.

Pedro Cortés, MD¹, Bhaumik Brahmbhatt, MD², Massimo Raimondo, MD², Vivek Kumbhari, MD², Yan Bi, MD, PhD², 23, Recurrent Episode of Acute Pancreatitis in Patients With Idiopathic Acute Pancreatitis and Fatty Pancreas on Endoscopic Ultrasound, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.