Abstracts S1451

less than 200 were treated with exogenous pancreatic enzymes (Creon, AbbVie Pharmaceuticals, and
North Chicago, Illinois, USA) and had their clinical symptoms and laboratory findings evaluated sequen-
tially at monthly intervals for a total of 6 months. 4) Symptoms of abdominal pain, cramps, bloating gas,
flatulence, diarrhea, large bulky stools, foul smelling stools, a requirement for double flushing, diarrhea
and constipation were each created on a 0-10 scale at each clinic visit. 5) Laboratory parameters consisting
of hemoglobin, blood urea nitrogen creatinine albumin, levels of vitamin A, vitamin D and vitamin E and
the prothrombin time were recorded at each clinic visit.
Results: Symptoms in most patients improved by 3 months and continued to improve throughout the study
period. Body weight, appetite, and the laboratory parameters improved more slowly but progressively.
Conclusion: 1) individuals with unexplained abdominal symptoms should be evaluated utilizing a stool
elastase its determination. 2) Individuals with stool elastase levels less than the lower limit of normal have a
clinical disease, subclinical EPI. 3) Subclinical EPI responds to therapy with exogenous pancreatic enzyme
supplementation. Conclusion: Subclinical EPI is a disease process that should be identified and treated.
2651
Gallbladder Polyps and Intraductal Papillary Mucinous Neoplasms in Patients With Primary
Sclerosing Cholangitis
available data on the prevalence of gallbladder polyp or IPMN in patients with PSC is sparse. This study
is aimed to investigate the prevalence of gallbladder polyp and IPMN in patients with PSC.
Methods: In this cross-sectional chart review study, 356 consecutive patients with the diagnosis of pri-
mary sclerosing cholangitis based on Magnetic Resonance Cholangiopancreatogram (MRCP), Endo-
scopic Retrograde Cholangiopancreatogram (ERCP) or liver biopsy, who had at least one abdominal CT
scan or MRI were included. Patients with gallbladder polyp and IPMN were identified based on abdomi-
nal CT scan or MRI. To calculate the prevalence of gallbladder polyp, patients who had absent gallbladder
on abdominal imaging were excluded. Age, gender, ethnicity, Body Mass Index (BMI), the presence of
IPMN, gallbladder polyp and Inflammatory Bowel Disease (IBD) including Ulcerative Colitis (UC) and
Crohn’s Disease (CD) were studied.
Results: The prevalence of IPMN and gallbladder polyp in patients with PSC was 11.8% (42/356) and
12.9% (31/240), respectively. The patients with PSC and IPMN compared to those without IPMN did not
harbor any statistically significant difference in gender or race distribution, mean BMI, the frequency of
IBD, UC or CD (Table 1). Additionally, there was no significant difference in the gender or race distribu-
tion, mean BMI, the frequency of IBD, UC or CD in patients with gallbladder polyp and patients without
gallbladder polyp (Table 2). However, there was a statistically significant age difference between patients
with IPMN and gallbladder polyp compared to those without IPMN and gallbladder polyp, respectively.
Conclusion: PSC might be associated with increased prevalence of IPMN and gallbladder polyp. This
association seems to be independent from underlying IBD, race and gender. In patients with PSC, older
age is associated with increased frequency of IPMN and gallbladder polyp.

Babak Torabi Sagvand, MD, Gursimran Kochhar, MBBS, MD, Bo Shen, MD, FACG. Cleveland Clinic
Foundation, Cleveland, OH
2652
Introduction: Patients with primary sclerosing cholangitis (PSC) are known to be at increased risk of
Clinical Utility of MRCP in Biliary Disease Treatment: A Review of the Literature
cholangiocarcinoma and gallbladder carcinoma. Gallbladder polyp and intraductal papillary mucinous
neoplasm (IPMN) are also known to have malignant potential. The prevalence of gallbladder polyp and Jean Sebastien Rowe, MD1, Sanmeet Singh, MD2. 1Cooper University Hospital, Philadelphia, PA; 2Univer-
IPMN in general population has been estimated 4.3% – 6.9% and less than 3%, respectively. However, the sity of Illinois at Chicago, Chicago, IL

Introduction: Magnetic Resonance Cholangiopancreatography ( MRCP) is one of the newer imaging

modalities used to evaluate hepatobiliary system pathologies. Studies have shown that it is the most
[2651_A] Characteristics of patients with primary sclerosing cholangitis and IPMN accurate and least invasive tool to detect abnormalities in the biliary ducts. This review of the world
compared to patients with primary sclerosing cholangitis without IPMN literature will serve to uncover the benefits of utilizing this technique in order to obtain more precise
diagnoses, better patient outcomes, and lower overall healthcare costs.
PSC and IPMN PSC without IPMN Methods: We reviewed the world literature on MRCP, including some controversial published discussions
from other continents (non-USA).
Number of patients (%) 42/356 (11.8) 314/356 (88.2) Results: There is significant variability in the use of MRCP in different countries but no general agree-
ment. MRCP is the most sensitive and specific imaging modality at diagnosing biliary cholelithiasis.
Age, mean + SE, years 63.7 + 1.5* 54.5 + 1.0* MRCP is currently understudied and underutilized in the USA. Benefits of using MRCP may override its
cost. No potential for superbug infections during MRCP unlike during ERCP.
Female/Male 18/24 95/219 Conclusion: Although there is still much controversy and variability between different countries and
institutions as to the clinical role of MRCP, it is a very important non-invasive application that is being
Number of Caucasion (%) 39 (92.9) 273 (86.9)
increasingly described and put into clinical practice. For example, it is particularly useful in identifying
Number of African Americans (%) 3 (7.1) 30 (9.6) stones, pancreatic carcinoma, liver transplant rejections, and anatomical variants in the pediatric popula-
tion (Figure1). While it is more expensive, MRCP can potentially lower healthcare costs as it can pick up
Number of patients from other None 11 (3.5) incidental findings to prevent complications in patients with comorbid conditions.
ethnicities (%)

BMI, mean + SD, Kg/m2 26.8 + 4.8 27.4+ 7.7

Number of patients with IBD (%) 32 (76.2) 238 (75.8)

2653
Number of patients with UC (%) 25 (59.5) 186 (59.2)
Diagnostic Accuracy of Pre-procedure MRI/MRCP in Patients Undergoing ERCP With Minor
Number of patients with CD (%) 7 (16.7) 46 (14.7) Papilla Cannulation in the Detection of Pancreas Divisum
Number of patients with IC (%) None 6 (1.9)
Kara L. Raphael, MD, Parit Mekaroonkamol, MD, Rushikesh Shah, MD, Sunil Dacha, MD, Qiang Cai,
Abbreviations; PSC: Primary Sclerosing Cholangitis, IPMN: Intra-ductal Papillary Mucinous Neoplasm, SE: Stand- MD, PhD, FACG, Steven A. Keilin, MD, FASGE, Field F. Willingham, MD, MPH. Emory University School
ard Error, SD: Standard Deviation, BMI: Body Mass Index, IBD: Inflammatory Bowel Disease, UC: Ulcerative of Medicine, Atlanta, GA
Colitis, CD: Crohn’s Disease, IC: Indeterminate Colitis
*Statistically significant difference, P value = 0.0007
Introduction: Pancreas Divisum (PD) is the most common congenital anatomic abnormality of the
pancreas, affecting 5-10% of the US population. PD is often asymptomatic, however, pancreatitis is pre-
sumed to develop due to decreased flow across a stenotic minor papilla. Endoscopic retrograde cholan-
giopancreatography (ERCP) is the gold standard diagnostic modality for PD, however, it carries the risk
for potential complications. The purpose of this study was to evaluate the diagnostic yield of magnetic
resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) in detecting PD.
[2651_B] Characteristics of patients with primary sclerosing cholangitis and gallbladder
Methods: This was a single center retrospective analysis of patients in our tertiary referral center who
polyp compared to patients with primary sclerosing cholangitis without gallbladder polyp underwent ERCP with diagnostic confirmation of PD between April 2009 and November 2016. Patient
demographics, pre-procedural MRCP, and clinical co-variates were examined, and their impact on diag-
PSC and GBP PSC without GBP nosis was evaluated with univariate analysis.
Results: In this cohort, 82 patients with PD underwent 173 ERCPs. Complete data from the initial
Number of patients* (%) 31/240 (12.9) 209/240 (87.1) ERCP and pre-procedural MRCP was available for 79 (96%) patients. None of the MRCPs were secretin-
enhanced. MRCP identified PD in 50 patients (63%) and did not identify PD in 29 (37%). Females were
Age, mean + SE, years 59.2 + 2.7** 52.1 + 1.2** more likely than males to have PD diagnosed on MRCP (OR 3.33, CI 1.26-8.78, p=0.013). Age, race,
history of smoking, alcohol use, and opioid use were not significantly different between groups (p=0.85,
Female/Male 11/20 60/149
p=0.08, p=0.44, p=0.11, and p=0.99, respectively). Anatomic factors including presence of a native papilla,
Number of Caucasions (%) 28 (90.3) 178 (85.2) complete versus partial PD, presence of an IPMN, Santorinicele, annular pancreas, or anomalous pancrea-
tobiliary junction were also similar between the two groups (p=0.81, p=0.14, p=0.62, p=1.00, p=1.00, and
Number of African Americans (%) 2 (6.5) 25 (12.0) p=0.53 respectively). Additionally, neither a history of prior pancreatitis nor a history of pancreatic stent
exchange (p =0.07 and p=0.19) were correlated with absence of a diagnosis of PD on MRCP.
Number of patients from other 1 (3.2) 6 (3.8) Conclusion: Pancreas divisum may not be detected by pre-procedure non-secretin enhanced MRI/
ethnicities (%) MRCP in over one third of patients undergoing ERCP with minor papilla cannulation. The presence of
other pancreatic anatomic variants, as well as prior manipulation or inflammation of the pancreas, did not
BMI, mean + SD, Kg/m2 25.9 + 3.9 27.1 + 6.6
appear to impact the diagnostic yield.
Number of patients with IBD (%) 26 (83.9) 160 (76.6)

Number of patients with UC (%) 22 (71.0) 117 (56.0)

Number of patients with CD (%) 3 (9.7) 41 (19.6)

2654
Number of patients with IC (%) 1 (2.2) 2 (1.0)
The Optimal Choice to 1 Stage Procedure for the Treatment of Cholecysto-choledocholithiasis
Abbreviations; PSC: Primary Sclerosing Cholangitis, IPMN: Intra-ductal Papillary Mucinous Neoplasm, GBP:
Gallbladder Polyp, SE: Standard Error, SD: Standard Deviation, BMI: Body Mass Index, IBD: Inflammatory Bowel Aldo Bove, MD, PhD1, Raffaella Di Renzo, MD1, Gino Palone, MD2, Alessandro Bennato, MD1, Lucia
Disease, UC: Ulcerative Colitis, CD: Crohn’s Disease, IC: Indeterminate Colitis Marino, MD1, Giuseppe Bongarzoni, MD1. 1University “G.D’Annunzio” Chieti-Pescara, Chieti, Abruzzi,
*To evaluate the prevalence of gallbladder polyp, out of 356 patients with PSC, 116 patients who had absent Italy; 2University “ G.D’Annunzio” Chieti-Pescara, Chieti, Abruzzi, Italy
gallbladder on abdominal imaging were excluded.
** Statistically significant difference, P value = 0.03
Introduction: The one-stage procedure for the treatment of cholecysto-choledocolithiasis turns out to
be optimal in terms of reduction of costs and patient’s compliance. We utilized trans-cystic clearance

© 2017 by the American College of Gastroenterology  The American Journal of GASTROENTEROLOGY

S1452 Abstracts
[2652A]  .
[2652B]  .
and intra-operative papillotomy through rendez-vous technique. There still lacks a procedure conform
to every case, hence it would be appropriate to know preliminarily the best procedure for each specific
patient. The goal of this study was to evaluate the reliability of pre-operative parameters to address the
most suitable surgical procedure.
Methods: From January 2008 to December 2015, we observed 1818 patients affected by gallbladder
stones; among these, 186 (10.5%) were also affected by calculi of the bile duct. 180 consecutive patients
underwent the single stage treatment. The group was composed of 102 women and 78 men and the aver-
age age was 53 years old (32-77). Patients were divided into two different groups according to the degree
of the jaundice (< or >2gr/dL), the bile duct’s diameter(< or >1,2 cm) and the calculi’s diameter (< or >1
cm). Later, the patients were directed to the trans-cystic clearance procedure (Group A, 141 patients) or
to the rendezvous procedure (Group B, 39 patients). We prospectively analyzed each group based on sex,
age, surgical time, conversion rate, success rate of proposed treatment, post-operative complications and
hospital stay.
Results: Trans-cystic clean-up for group A patients was successful in 134 patients (90%), 2 patients
needed to undergo a laparo-endoscopy (failure) and 5 patients underwent laparotomy with a conversion
rate of 3.2%. 35 patients (89%) of group B obtained VBP clean-up through rendezvous, 1 patient obtained
clean-up through simple trans-cystic procedure ( failure), while for 3 patients (9.1%) it was necessary to
convert the surgery. Post-operative complications showed similar percentages for both groups. However,
the surgical time turned out to be longer for the rendez-vous group ( 207.3±88.5 m vs 124±52.7 m) with
a statistically significant difference(. p value = 0.0001).
The American Journal of GASTROENTEROLOGY
Conclusion: The one-stage procedure for the treatment of cholecysto-choledocolithiasis was possible in
90% of the cases utilizing a surgical technique selected according to the patient’s case history.
2655
Management of Choledochal Cysts: An Institutional Review
Erica Wadas, MD, Joan Chandra, MD, Timothy B. Gardner, MD, MS. Dartmouth-Hitchcock Medical
Center, Lebanon, NH
Introduction: Choledochal cysts are congenital abnormalities characterized by cyst formation and dila-
tion of the biliary tree. They are a rare condition more common in females with the highest incidence
in the United States estimated at 1 in 13,500 live births (1). They can be clinically silent, cause biliary
obstruction and/or transform to malignancy. Management is controversial because statistics regarding
malignant transformation vary widely. Estimates from select studies vary from 10% (2) to 26% (3). This
study was performed to review the natural history and management of choledochal cysts at our institu-
tion.
Methods: Patient charts from 2009-2017 were obtained with the following ICD9 and ICD10 codes:
Choledochal cyst (Q44.4); biliary cyst (K83.5); other specified disorders of the biliary tract (576.8); anom-
alies of gallbladder, bile ducts, and liver (751.69); biliary atresia (751.61); other congenital malformations
of bile ducts (Q44.5); and intrahepatic bile duct carcinoma (155.1, C22.1). A total of 2,546 charts were
identified. Charts were then reviewed for the presence of choledochal cysts.
Results: Eleven patients with choledochal cysts were found. Ten out of the 11 were female. Five had Type
I cysts (one of these patients also had a Type II cyst). Five had Type II cysts. There was only one patient
with a Type III cyst and only one with a Type IV cyst. Five out of the 11 patients with choledochal cysts
were managed with surgical removal with either a Roux-en-Y hepaticojejunostomy, Roux-en-Y choledo-
chojejunostomy or Whipple procedure depending on other patient factors. The patient with the Type III
cyst was lost to follow-up after diagnosis of the cyst.
Conclusion: Management of choledochal cysts at our institution varied with about half opting for surgi-
cal removal and half opting for serial follow-up with imaging. Given the rarity of the disease and varied
results regarding transformation to malignancy, an individualized patient approach should be taken.
Future research aims could include creation of a database of patients with choledochal cysts, given that
malignant transformation and management will likely vary by type of cyst, patient characteristics, and
patient preference.
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