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Background and Aims The optimal timing of endoscopy in patients with peptic ulcer bleeding (PUB) remains unclear. The aim of this study was to examine the association between timing of endoscopy and mortality in PUB. Methods In a nationwide cohort study based on a database of consecutive patients admitted to the hospital with PUB in Denmark, patients were stratified according to the presence of hemodynamic instability at presentation and American Society of Anesthesiologists (ASA) score. Using descriptive statistics and logistic regression analyses, we identified optimal time frames for endoscopy and analyzed the association between timing of endoscopy and in-hospital mortality after adjusting for confounding factors. Results In total, 12,601 patients were included. We did not find any universal association between timing of endoscopy and mortality in hemodynamically stable patients with an ASA score of 1 to 2. In hemodynamically stable patients with an ASA score of 3 to 5, endoscopy 12 to 36 hours after admission to the hospital was associated with lower in-hospital mortality (OR, .48; 95% CI, .34-.67) compared with endoscopy outside this time frame. In patients with hemodynamic instability, endoscopy 6 to 24 hours after admission to the hospital was associated with lower in-hospital mortality (OR, .73; 95% CI, .54-.98) compared with endoscopy outside this time frame. Conclusions Timing of endoscopy is associated with mortality in patients with PUB and an ASA score of 3 to 5 or hemodynamic instability. Our findings suggest that in these patients, a period of time to optimize resuscitation and manage comorbidities before endoscopy may improve outcome.

825 Early Implementation of Precut Sphincterotomy for the Prevention of Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis (PEP): Cochrane Collaboration Meta-Analysis of Randomized Controlled Trials Frances TSE*, Siwar Albashir, Yuhong Yuan, Paul Moayyedi, Grigorios I. Leontiadis, Alan N. Barkun McMaster University, Hamilton, ON, Canada; McGill Univserity, Montreal, QC, Canada Background and Aim: Precut sphincterotomy, often used as a salvage technique for difficult cannulation, is considered an independent risk factor for post-ERCP complications. It remains controversial as to whether the increased risk is due to the precut itself or to the prolonged cannulation attempts prior to the use of precut. Early use of precut has been postulated to improve cannulation success and reduce the risk of PEP. We conducted a meta-analysis of randomized controlled trials (RCTs) of a strategy of early use of precut vs. a strategy of persistent attempts with conventional cannulation (CC) +/delayed use of precut for the prevention of PEP. Methods: We searched MEDLINE, EMBASE, CENTRAL, CINAHL up to September 2013. Conference proceedings from DDW, UEGW and ACG were searched. RCTs that compared early use of precut vs. persistent attempts with CC +/delayed use of precut were included. Study selection, data extraction and quality assessment were conducted independently by two authors. Primary outcome was incidence of PEP. Secondary outcomes included severity of PEP, CBD cannulation success with the randomized technique (primary cannulation success), eventual overall CBD cannulation success, bleeding, cholangitis, perforation and mortality. Revman 5.1 was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI, MandelHaenszel method; random effects model). Heterogeneity was assessed by Chi test (P!0.15) and I test (O25%). Results: Eight RCTs (1121 participants) met the inclusion criteria. Definitions of difficult cannulation were variable. The incidence of PEP in the early precut group was 4.6% compared to 7.5% in the CC group. Among patients with difficult cannulation, there was a trend favoring the early use of precut compared to persistent attempts with CC +/delayed use of precut for the prevention of PEP (RR 0.62; 95% CI 0.38-1.01; I Z0%) (Figure 1). The early use of precut was associated with a significantly higher primary cannulation success (91.0% vs. 58.7%; RR 1.64; 95% CI 1.28-2.10; I Z88%) with no significant increase in complications compared with persistent attempts with CC +/delayed use of precut. There was no significant difference in the overall CBD cannulation success between the two strategies (RR 1.00; 95% CI 0.96-1.04; I Z28%). Conclusion: In patients with difficult CBD cannulation, the early use of precut sphincterotomy by experienced endoscopists increases the primary cannulation success and does not appear to increase the risk of PEP or other complications compared to persistent attempts with conventional cannulation. Further RCTs are needed to confirm these findings.

Pancreatic Duct Guidewire Placement for Biliary Cannulation for the Prevention of Post-ERCP Pancreatitis (PEP): Cochrane Collaboration Meta-Analysis of Randomized Controlled Trials Frances TSE*, Majidah Bukhari, Yuhong Yuan, Paul Moayyedi, Grigorios I. Leontiadis, Alan N. Barkun Medicine, McMaster University Medical Centre, Hamilton, ON, Canada; Medicine, McGill University Health Centre, Montreal, QC, Canada Background and Aim: Difficult cannulation is a risk factor for PEP. It has been postulated that the pancreatic duct guidewire (PGW) technique may improve biliary cannulation success and reduce the risk of PEP. We conducted a metaanalysis of randomized controlled trials (RCTs) of PGW technique vs. persistent attempts with conventional cannulation (CC), precut sphincterotomy, or pancreatic duct (PD) stent in patients with difficult cannulation for the prevention of PEP. Methods: We searched MEDLINE, EMBASE, CENTRAL, CINAHL up to October 2012. Conference proceedings from DDW, UEGW and ACG were searched. RCTs that compared PGW technique vs. persistent attempts with CC, precut sphincterotomy or PD stent in patients with difficult cannulation were included. Study selection, data extraction and quality assessment were conducted independently by two authors. Primary outcome was incidence of PEP. Secondary outcomes included CBD cannulation success with the randomized technique, overall CBD cannulation success, bleeding, cholangitis, perforation and mortality. Revman 5.1 was used to calculate pooled risk ratios (RR) with 95% confidence intervals (CI, Mandel-Haenszel method; random effects model). Heterogeneity was assessed by Chi test (P 0.15) and I test ( 25%). Results: Six RCTs (503 participants) met the inclusion criteria. Definitions of difficult cannulation were variable. Among the two studies that compared PGW with precut, the incidence of PEP was 21.4% in the PGW group vs. 7.3% in the precut group (RR 2.83; 95% CI 0.96-8.34; I 0%) (Fig 1). Among the three studies that compared PGW with persistent CC (two with contrastand one with guidewire-assisted), the incidence of PEP was 12.9% in the PGW group vs. 8.0% in the CC group (RR 1.63; 95% CI 0.84-3.19; I 0%) (Fig 1). In a post-hoc pooled analysis of the five studies that compared PGW vs. precut or persistent CC, PGW technique significantly increased the risk of PEP compared to precut or persistent CC (RR 1.90; 95% CI 1.08-3.36; I 0%). In the one study that compared PGW vs. PD stent, there was no significant difference in the risk of PEP between the two techniques (RR 0.36; 95% CI 0.04-3.30). There was no significant difference in CBD cannulation success with the initial technique the patient was randomized to (RR 1.02; 95% CI 0.84 1.24; I 66%) or eventual overall CBD cannulation success (RR 1.05; 95% CI 0.90 1.22; I 67%) between PGW technique vs. precut, persistent CC or PD stent. Conclusion: In patients with difficult CBD cannulation, the PGW technique appears to be associated with an increased risk of PEP. PGW is not superior to precut sphincterotomy, persistent attempts with conventional cannulation or PD stent in achieving CBD cannulation. Sole PGW should be discouraged. PD stenting after use of a PGW cannulation technique may reduce the risk of PEP yet requires assessment. Sa1529 Nafamostat for Prevention of Post-ERCP Pancreatitisa MetaAnalysis of Randomized Controlled Trials Naga Swetha Samji*, Anupama Inaganti, Rajan Kanth, Sarah D. Komanapalli, Mainor R. Antillon, Praveen K. Roy Internal Medicine, Marshfield clinic, Marshfield, WI; Gastroenterology and Hepatology, Oschner Clinic, New Orleans, LA Purpose: Post ERCP pancreatitis (PEP) is a common complication after ERCP and contributes significantly to the morbidity and mortality of the procedure. Nafamostat, a protease inhibitor, inhibits serine proteases such as trysin, kallikrien, C1r and C1s, thrombin, plasmin and thereby decrease the risk of PEP. Several randomized controlled trials (RCTs) have studied the effectiveness of nafamostat in PEP. We performed a meta-analysis of the RCT’s to evaluate the prophylactic effect of nafamostat in PEP. Methods: Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched (through 11/12). All the studies assessing the efficacy of nafamostat in preventing post ERCP pancreatitis are included. Standard forms were used to extract data by two independent reviewers. Data regarding the following outcomes were extractednumber of patients with mild, moderate and severe pancreatitis in nafamostat group vs control group, number of patients with post ERCP hyperamylasemia, incidence of PEP in high risk and low risk patients in nafamostat vs control group. Results: 6 RCT’S (n 2254) met the inclusion criteria. 2 studies used 50mg of nafamostat and 4 studies used 20 mg of intravenous nafamostat. Administration of nafamostat was started 30 min to 1 hour before the procedure and continued for 12-24 hours after the procedure. Two studies compared nafamostat with gabexate and 5 studies compared nafamostat with placebo. Heterogenity was present and thus a random effect model was used for the analysis. Nafamostat decreased the risk of developing PEP ( RR 0.42;95% CI 0.290.62,p 0.0001). The number needed to treat(NNT) was 21 (95% CI 14-40). In subgroup analysis, nafamostat is found to decrease PEP in high risk patients (RR 0.54, 95% CI 0.30-0.96, p 0.03),NNT 28. Nafamostat also decreased the risk of PEP in low risk patients (RR 0.28,95% CI 0.15-0.53,p 0.0001),NNT 13. Nafamosat did not lower the risk of Post ERCP hyperamylesemia (RR 1.04,95% CI 0.78-1.39, P 0.7). Mild pancreatitis was significantly lower in nafamostat group compared to placebo group (RR 0.4, 95% CI 0.28-0.69,p 0.001). Moderate pancreatitis was significantly lower in nafamostat group (RR 0.37, 95% CI 0.140.95,p 0.03).No sufficient data to assess risk of developing severe pancreatitis. Risk of developing PEP was same in both nafamostat and gabexate group (RR 1.01 95% CI 0.60-1.70,p 0.94). Conclusion: Prophylactic nafamostat decreases the risk of post ERCP pancreatitis in both high risk and low risk groups. Further larger RCT’s are needed to confirm to the above results. Figure 1. Meta-analyses for post-ERCP pancreatitis among trials comparing PGW vs. precut sphincterotomy, PD stent or persistent attempts with conventional cannulation Abstracts