score analysis revealed sig. less necrosis in the animals subjected toprevious topical “L”.Conclusion: The “Sh.T-CDL” model mimicks with remarkable closenessthe physiopathogenic features of biliary acute pancreatitis. The ductal freelesions, the “spotty” distribution of the pancreas’ inflammatory foci and thesig. altenuation of necrosis by “L” put in evidence the pivotal role of AARarising from the periVaterian duodenum.

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Gastroenterologist (GE)-administered propofol (P) for ERCP/EUS issuperior to meperidine and midazolam (M/M) for both immediateand delayed recovery parameters: results of a prospective,randomized trialJohn J Vargo, MD, Gregory Zuccaro, Jr, MD, FACG, John A Dumot,DO, J Brad Morrow, MD, Darwin L Conwell, MD, Patricia A Trolli,RN, Kenneth Shermock, Pharm D, Walter G Mauer, MD, ClevelandClinic Foundation, Cleveland, OH

Background: P is an effective-sedative hypnotic with a short half-life andpotential for rapid recovery.Purpose: Evaluate efficacy and safety of P with emphasis on immediateand delayed (24 hr) post-procedural recovery.Methods: Pts undergoing elective ERCP/EUS randomized to P or M/M. Inaddition to standard monitoring, pts were monitored with end-tidal CO2

capnography, providing real time graphic assessment of respiratory activ-ity. This allowed GE to adjust P dose at earliest signs of respiratorydepression. Pt/GE satisfaction evaluated with visual analog scales. Ablinded observer assessed time to recovery using a 10-point scale every 15minutes until discharge threshold (10/10) was achieved. Pts interviewed 24hr postprocedurally to determine recovery of activity and food intake.Results: 75 pts randomized (38 P, 37 M/M). Groups were similar in termsof age/gender/ASA class/procedure duration. There were no serious ad-verse events in either group. Pt/GE satisfaction scores were similar. Therewere dramatic differences in recovery profiles (table). Significantly more Ppts able to independently transfer immediately after procedure (71.1% vs29.7%, p � 0.001) and achieved normal levels of activity and food intake24 hrs after the procedure (71% vs 43%, p � 0.028).

Propofol(n � 38)

Mep/Mid(n � 37) P value

Recovery time (min) 18.6 � 6.5 70.5 � 7.1 �0.001# pt recovered @ 15 min (%) 29 (76.3) 3 (8.1) �0.001# pt recovered @ 30 min(%) 38 (100) 6 (16.2) �0.001# pt recovered @ 60 min (%) 38 (100) 27 (72.9) �0.001

Conclusions: (1) With use of capnography, GE-administered P is safe,provides a dramatically shorter recovery time and significantly better ptactivity level and food intake 24 hr post-procedurally (2) P providesequivalent pt/GE satisfaction (3) With appropriate training/monitoring, P ispreferable sedative/hypnotic for ERCP/EUS

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Prolonged survival after liver transplantation in a case of primarysclerosing cholangitis with incidentally discovered advanced gallbladder carcinomaShivakumar Vignesh1, Kanchana Thirumalesh1, Kaul Vivek1, RothsteinD Kenneth2, Manzarbeitia Cosme3, Reich J David3 and Munoz JSantiago2*. 1Department of Gastroenterology, United States;2Department of Hepatology; and 3Department of Transplant Surgery,Albert Einstein Medical Center, Philadelphia, PA.

Background: Patients with gallbladder carcinoma have an extremely poorprognosis. Patients with stage III carcinoma have survival of less than 6months even with extended resection. Liver transplantation (LT) is con-traindicated in cirrhotic patients with gall bladder carcinoma. However,there are two reports of liver transplantation in patients with incidentally

discovered gall-bladder carcinoma. Both reports described patients withearly stage gall-bladder carcinoma. We report a case of prolonged survivalafter successful liver transplantation in a patient with incidentally discov-ered stage III gall bladder carcinoma.Case Description: A 57 year old black male with primary sclerosingcholangitis (PSC) and end stage liver disease underwent orthotopic livertransplantation at our Institution. The explanted gall bladder showed anincidental 2cm mass with 4mm extension into the hepatic parenchyma.Pathology revealed moderately differentiated invasive adenocarcinoma ofthe gall bladder with extension through the hepatic capsule into the hepaticparenchyma. Tumor was staged as T3NOMO (stage III). No evidence ofany other adjacent organ involvement or distant metastasis was found.Follow-up: He had an excellent post-transplant recovery. A brief episodeof acute cellular rejection 3 months post LT responded promptly to meth-ylprednisolone recycle. Since then, he has been maintained on tacrolimus,mycophenolate mofetil and prednisone. We have closely followed hiscourse 18 months post transplantation, with extensive imaging studiesrevealing no metastases or local recurrence and he continues to do verywell. The patient has shown no evidence of tumor recurrence and maintainsgood liver function 18 months post liver transplantation.Conclusions: Patients with primary sclerosing cholangitis complicated bycholangiocarcinoma or gallbladder carcinoma are known to have a poorprognosis and tumor recurrence after LT. Our patient has shown prolongedsurvival despite having stage III gallbladder carcinoma. This is the firstreported case of successful LT in a patient with stage III gallbladdercarcinoma.

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Direct percutaneous endoscopic jejunostomy (DPEJ) is safe andeffective for long-term nutrition in severe pancreatitisVivek Raj MD UA and Virender K Sharma MD UA*. Little Rock, AR,United States.

Purpose: In severe acute pancreatitis, positive nitrogen balance improvessurvival. Currently, TPN is the most commonly used method for providingnutrition. However, it is expensive and is associated with significant com-plications. In patients with pancreatitis, post ligament of Treitz feeding issafe, effective and less expensive. Currently, nasojejunal (NJ) tube orsurgical jejunostomy are used for jejunal access. NJ tubes are poorlytolerated and are frequently dislodged. Surgical jejunostomy requires lapa-roscopy or laparotomy and is infrequently used. DPEJ is a safe method forjejunal feeding (Gastrointest Endos 1996; 44: 536). The use of DPEJ forlong-term enteral nutrition in patients with pancreatitis has not been re-ported. The objective of this study was to assess the feasibility, efficacy andsafety of DPEJ for long-term enteral nutrition in patients with severe acutepancreatitis.Methods: Five patients (mean age � 35.2 yrs; range 21–48; 2M,3F) withsevere acute pancreatitis diagnosed by CT scan underwent DPEJ placementfor long-term enteral nutrition. Indication for DPEJ placement were inabil-ity to tolerate oral feeds after 7 days of conservative management (n � 2);persistent pseudocyst on TPN, ERCP-normal pancreatic duct, loss of accessdue to central line sepsis (n � 1); and PD stricture with pseudocystrequiring prolonged TPN despite endoscopic pseudocyst drainage (n � 2).DPEJ was placed using our previously published technique (Surg Endosc2000; 14 203).Results: DPEJ placement was successful in 4/5 patients (1 failed due toduodenal obstruction from pancreatitis). There were no immediate orlong-term complications. DPEJ feeding was started 24 hours post place-ment, and was well tolerated. There was no clinical, laboratory or radio-logical evidence of recurrent or worsening pancreatitis. Three patients wereable to resume oral feeds and DPEJ was removed after 2, 5 and 6 months,respectively. The DPEJ site healed without problems. One patient with PDstricture (body) underwent distal pancreatectomy. The second patient has along stricture in the head of the pancreas and is being considered for totalpancreatectomy. She has been on, and has tolerated DPEJ feeds for 6months without complication

S99AJG – September, Suppl., 2001 Abstracts

Conclusions: In patients with severe pancreatitis requiring prolonged pan-creatic rest, enteral feeding via DPEJ is effective and safe and can be usedinstead of TPN. Prospective studies comparing DPEJ with TPN in severeacute pancreatitis are warranted.

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Antioxidant levels in acute pancreatitis (AP)Dhiraj - Yadav, E P Norkus and C S Pitchumoni*. 1Gastroenterology,Our Lady of Mercy University Medical Medical Center, Bronx, NY,United States; 2Biomedical Research, Our Lady of Mercy UniversityMedical Center, Bronx, NY, United States; and 3Gastroenterology, OurLady of Mercy University Medical Center, Bronx, NY, United States.

Purpose: Oxidative stress due to free radicals and lipid peroxides arebelieved to play a role in development of AP and its systemic complica-tions. Our aim was to estimate the serum levels of nonenzymatic fat-solubleantioxidants (AO) in different forms of AP and to correlate the AO levelswith the severity of AP.Methods: AO levels were estimated by high performance liquid chroma-tography in the serum collected within 24 hours of admission in 39 patientsadmitted to our hospital with AP (Biliary 16, alcohol 10, other etiology 13).31 healthy individuals served as controls. Data was collected on demo-graphics, etiology WBC, HCT, serum amylase/lipase levels, liver func-tions, BUN/Cr, sono, CT and Ranson score on admission and 48 hours. AOlevels in controls were compared -a) to patients with alcoholic or biliaryAP, b) classifying patients into mild (Ranson �3) or severe AP (Ranson�3). The AO estimated were -� and �-tocopherol, lutein, �-cryptoxanthin,lycopene, � and �-carotene.Results: AO depending on etiology: Alcoholic AP patients were predom-inantly males (M:F- 9:1 in the alcoholic AP group, 4:12 in biliary APgroup, and 9:22 in the controls) and their mean age (40.9 � 9 yrs) wassignificantly less than Biliary AP (53 � 17 yrs, M:F- 4:12) and controls(55 � 15 yrs, M:F9:22) (p � 0.03). Compared to controls, the mean levelsof all AO were significantly lower in patients with alcoholic AP (�-tocopherol p � 0.000, �-tocopherol p � 0.005, lutein p � 0.004, �-cryp-toxanthin p � 0.007, lycopene p � �0.000, �-carotene p � 0.028,�-carotene p � 0.037), however in biliary AP only �cryptoxanthin (p �0.007) and lycopene (p � �0.000) were significantly lower than controls.

AO depending on severity: The mean levels of �-tocopherol (p � 0.000),�-cryptoxanthin (p � 0.003) and lycopene (p � �0.000) were significantlylower in patients with both mild and severe AP as compared to controls.Rest of the AO had similar mean levels in the 3 groups (mild AP, severeAP and controls). No significant differences were seen in the mean levelsof AO between patients with mild v/s severe AP.Conclusions:1. All serum AO were depleted in patients with alcoholicpancreatitis, perhaps a reflection of their longstanding poor nutrition, andnot to AP itself.

2. �-tocopherol, �-cryptoxanthin and lycopene levels were decreased inall forms of AP

3. The was no differences in the serum AO levels based on severity ofAP (mild v/s severe) within the first 24 hours of admission.

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Endoscopic pancreatic function testing (TTS-PFT) in a series ofpatients referred to a tertiary medical center for evaluation of acuterecurrent pancreatitis (ARP)Luke J Weber, MD, Darwin L Conwell, MD, Gregory Zuccaro, MD*, JBrad Morrow, MD, John J Vargo, MD, John A Dumot, DO, R MatthewWalsh, MD and Patricia Trolli, RN, CGRN. 1The Pancreas Clinic,Departments of Gastroenterology and General Surgery, ClevelandClinic Foundation, Cleveland, Ohio, United States.

Purpose: The initial evaluation of the patient with ARP is challenging andincludes attempting to exclude chronic pancreatitis (CP) by relying on avariety of structural imaging tests, such as computed tomography, magneticresonance, and endoscopic retrograde pancreatography (ERP). However,

evaluation of pancreatic function is uncommonly performed, primarily dueto a lack of a readily available test (Somogyi et al. Gastro 2001;120:708–717). Our group has developed a cholecystokinin (CCK) pancreatic func-tion test that is amenable to endoscopic collection. Our aim was to deter-mine the prevalence of pancreatic insufficiency (PI) by TTS-PFT among acohort of patients with ARP referred to a tertiary medical center.Methods: We reviewed the medical records of sequential patients referredfor evaluation of ARP who underwent CCK stimulated TTS-PFT. Diag-nosis of ARP was based on a history of at least two episodes of abdominalpain with documented elevations of serum amylase and lipase to greaterthan twice the upper limit of normal, without evidence of CP by structuralimaging. All study participants underwent TTS-PFT based on our protocol:IV CCK octapeptide (40 ng/kg/h, Sincalide, Bracco Diagnostics Inc.,Princeton, NJ) was started in the pre-procedure area. Duodenal fluid wascollected via a standard gastroscope (Olympus GIF 130) in four, ten-minutealiquots (t � 30, 40, 50 and 60 minutes) during CCK infusion. Fluid lipaseconcentrations were determined with a laboratory autoanalyzer. PI wasdefined as peak duodenal fluid lipase concentration (PDFLC) less than780,000 IU/L, with a sensitivity and specificity versus ERP of 83% and86%, respectively (Conwell et al. Gastro 2001;120:A646).Results: Sixteen patients were evaluated; two were excluded due to ERPfindings consistent with CP. Of the 14 patients, 10 were female. Median agewas 33.5 years (range 22–61). Median PDFLC by TTS-PFT was 1,754,100IU/L (range 559,200-2,344,200). Three of 14 patients (21%) met ourcriteria for PI by TTS-PFT; etiologies of ARP in these patients weresphincter of Oddi dysfunction, pancreas divisum, and idiopathic.Conclusions: A proportion of patients in our series did demonstrate evi-dence of pancreatic insufficiency. Oral pancreatic enzyme supplementsshould be offered to ARP patients with PI. This series suggests thatTTS-PFT is feasible and may prove to be complimentary to conventionalimaging modalities in the evaluation of ARP.

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Laboratory parameters in predicting biliary pancreatitisDhiraj - Yadav, Vidya - Subramanian, E P Norkus and C SPitchumoni*. 1Gastroenterology, Our Lady of Mercy UniversityMedical Center, Bronx, NY, United States; 2Gastroenterology, Our Ladyof Mercy University Medical Center, Bronx, NY, United States;3Biomedical Research, Our Lady of Mercy University Medical Center,Bronx, NY, United States; and 4Gastroenterology, Our Lady of MercyUniversity Medical Center, Bronx, NY, United States.

Purpose: Routine biochemical parameters identifying the etiology of acutepancreatitis (AP) assist in planning further diagnostic studies and appro-priate management sufficiently early in the course of AP. We conductedthis study to identify the usefulness of biochemical values in distinguishingbiliary AP from non-biliary AP.Methods: The data was from our prospective AP registry between 1996-1999, which included 176 AP patients: biliary (75) and non-biliary (101).Biliary AP was confirmed by presence of gallstones on sonogram, ERCPor surgery. Serum AST, ALT, ALP, bilirubin, amylase, lipase and lipase/amylase ratio within 48 hrs of admission were analyzed using logisticregression analysis to determine the best single variable (by analyzingmultiple thresholds) and to develop a more comprehensive multiple vari-able predictive model.Results: 1) The mean levels of ALT, AST, ALP, bilirubin, amylase weresignificantly higher in patients with biliary AP (p � �0.001) compared tonon-biliary AP. 2) Using single markers, serum bilirubin �3x normal hadthe best specificity (SP) (98%) and positive predictive value (PPV) (0.91),however the sensitivity (SS) was only 25% and area under receiver oper-ative characteristics curve (ROC) was 0.61. On the other hand, an ALT�4x normal (�150 U/L) produced the greatest predictive power underROC (0.76) with a high SP (88%) and PPV (0.80). (see table) 3) Next, wecreated a multiple variable model including all variables and found thatALT �4x normal � Bil �3x normal produced highest SS (72%), SP(86%), PPV and ROC increase to 93%, 0.89 and 0.91 respectively intro-

S100 Abstracts AJG – Vol. 96, No. 9, Suppl., 2001