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Background: The Institute of Medicine defines guidelines as statements to assist physician and patient decisions regarding appropriate health care in clinical situations. Guidelines are meant to create a succinct roadmap for diagnosis and treatment by analyzing and summarizing the abundance of medical studies. This is predicated on guidelines being unbiased and based on strong quality of evidence. Currently, though, no studies have reviewed the quality of the interventional medical subspecialty guidelines Methods: We reviewed the interventional medicine subspecialty society's websites for interventional guidelines. The American Society of Gastroenterology Endoscopy (ASGE), American Association of Diagnostic and Interventional Nephrology (ASDIN), American Association for Bronchology and Interventional Pulmonology, American Thoracic Society, CHEST, and Society for Cardiovascular Angiography and Interventions (SCAI) were reviewed for guidelines that graded the level of evidence, methods used to grade the evidence, and disclosures of conflicts of interest (COI). The data were evaluated in aggregate and by society. Results: 153 interventional guidelines were evaluated of which two were duplicates. 46% (n=70/151) of the interventional guidelines graded the quality of evidence. ASGE graded 72% (n=48/67) compared to 28% (n=22/78) by SCAI, and 0 (n=4) by ASDIN and 0 (n=2) by the pulmonary societies. Of the 3460 recommendations reviewed 11% (n=374) were supported by the highest quality of evidence, level A (multiple randomized controlled trials), 41% (n=1414) were level B (single or nonrandomized controlled trials), and 48% ((n=1645) were level C (expert opinion). See table 1 for breakdown by society. While SCAI used two systems to grade the level of evidence, ASGE used 5 different systems to grade its evidence. Furthermore, 62% (n=94/ 151) of the guidelines failed to comment on COI. Of the 57 articles that disclosed COI, 91% (n=52) reported potential conflicts. In total 1855 COI were reported of which 967 were non-research based COI. Authors with conflicts (n=320/705) averaged 5.8 conflicts/ authors. While the SCAI disclosed potential COI in 52% of their guidelines, ASGE did so in only 24% of their guidelines, and the ASDIN and pulmonary societies did not disclose COI. Conclusions: Majority of the medicine subspecialty interventional guidelines fail to grade the quality of evidence, and when present, most used lower quality evidence. Furthermore, most guidelines fail to comment on potential COI. When assessed, numerous COI were present. Interventional procedures carry unique risks to the patients and guidelines should ideally be based on strong quality of evidence. Future interventional guidelines should clearly state the quality of evidence for their recommendations, utilize a standard grading system, and be transparent regarding all potential biases. Table 1. Total number of practice guidelines with graded evidence and quality of evidence for recommendations

Background: The diagnosis of chronic pancreatitis in patients with characteristic symptoms but normal pancreatic imaging is challenging. Assessment of pancreatic function through collection of duodenal fluid following secretin stimulation testing (SST) has been advocated in this setting. The diagnostic accuracy of SST in detecting early chronic pancreatitis is not fully known. Aim: To determine if subjects with suspected chronic pancreatitis and abnormal SST subsequently develop histologic or radiographic changes of chronic pancreatitis compared with those with normal SST. Methods: We performed a retrospective review of subjects who received SST at our institution between January 1995 and December 2007 for suspected chronic pancreatitis. All had normal cross sectional and endoscopic imaging of the pancreas prior to SST. A positive test was defined as a peak bicarbonate level of

Purpose: Celiac crisis is a life-threatening syndrome where celiac disease presents with profuse diarrhea and severe metabolic disturbances. Celiac crisis in adults is believed to be uncommon and is not well documented. However, it is likely that many patients with celiac crisis are not definitively diagnosed. In order to improve awareness and to facilitate diagnosis, we reviewed cases of celiac crisis seen at Beth Israel Deaconess Medical Center in Boston, MA and Mayo Clinic in Rochester, MN. These data were used to identify presenting features, formulate diagnostic criteria for celiac crisis in adults and develop treatment strategies. Methods: We reviewed cases of biopsy proven celiac disease in the last 5 years. Celiac crisis was defined as acute onset or rapid progression of gastrointestinal symptoms attributable to celiac disease requiring hospitalization and/or parenteral nutrition along with at least 2 of the 7 factors listed below: 1.Signs of severe dehydration including hemodynamic instability or orthostasis 2.Neurologic dysfunction 3.Renal dysfunction: creatinine >2.0 4.Metabolic acidosis: pH 10 lbs Results: Twelve patients met the above criteria. Of these, 8 were women and 4 were men. 11 developed celiac crisis prior to diagnosis of celiac disease. IgA tissue transglutaminase titer was available for 11 patients. Of these, one had IgA deficiency, and all of the others had elevated tTG, eight with levels greater than 4 times the normal limits. Biopsies of the duodenum in all patients were consistent with a Marsh 3 score. HLA type was available for 10, of which 9 were positive for DQ2 and 1 for DQ8. Patients presented with severe dehydration, renal dysfunction, and electrolyte disturbances, of which hypocalemia was most common. All patients required hospitalization and intravenous fluids and five required parenteral nutrition. Six patients required corticosteroids. All patients had a rapid clinical response to gluten free diet. Conclusion: Celiac crisis is associated with high morbidity and although rarely described, does occur in adults, often without a clear precipitating factor. Patients presentingwith severe unexplained diarrhea and malabsorption should be tested for celiac disease and treatment with systemic steroids or oral budesonide considered. Nutritional support is often required in the short term but most patients ultimately respond to gluten avoidance. We are hopeful that our delineation of formal diagnostic criteria for celiac crisis will aid in identification and management of these patients.