The pathogenesis of chronic pancreatitis

To date, there is no consensus on the evolution of chronic pancreatitis. Comfort's initial proposal of acute pancreatitis progressing to chronic pancreatitis was discarded by protagonists of the 'separate' theory. Sarles thus stresses the de novo evolution of chronic pancreatitis-acinar protein hypersecretion associated with an imbalance of pancreatic stone promoting and inhibiting factors. However, the 'necrosis-fibrosis sequence' hypothesis of Kloppel and Mallet resurrects the probability of acute pancreatitis leading to chronic pancreatitis. Dimagno offers a unifying concept that the degree of acinar injury determines the natural history of pancreatitis. Uninhibited release of toxic free radicals could be a common end point for various aetiologies resulting in acute or chronic pancreatitis. The pathogenesis of chronic calcifying pancreatitis of the tropics is possibly no different from alcoholic chronic pancreatitis. Neurocrine and paracrine mechanisms have been offered to explain pain out of proportion to radiological and histological pancreatic abnormalities in minimal change chronic pancreatitis.

Chronic calcific pancreatitis of the tropics (CCPT): spectrum and correlates of exocrine and endocrine pancreatic dysfunction

The exocrine and endocrine pathophysiology of chronic calcific pancreatitis of the tropics (CCPT) remains elusive. The objective of this study was to evaluate the spectrum and correlates of the exocrine and endocrine pancreatic dysfunction in CCPT. Thirty-seven consecutive patients with a clinico-radiological diagnosis of CCPT were stratified into three subgroups: CCPT-normal glucose tolerance (NGT), CCPT-abnormal glucose tolerance (IGT) and CCPT-diabetes mellitus (DM). Ten ketosis resistant young diabetic (KRDY) patients, 10 classical insulin dependent diabetes mellitus (IDDM) patients and 18 healthy matched controls were included for comparison. Fecal chymotrypsin (FCT) levels and blood C-peptide levels (basal and post i.v. glucagon stimulation) were estimated for assessing the exocrine and endocrine pancreatic functions, respectively. Sonography was performed to evaluate the pancreatic size and ductal diameter. Pancreatic exocrine-endocrine correlation was examined by studying the C-peptide/fecal chymotrypsin ratio (CP/FCT) (CP/FCT of normal controls = 1). Mean FCT levels in all 3 subgroups of CCPT (NGT: 3.4 micrograms/g; IGT: 0.82 microgram/g; DM: 2.4 micrograms/g) were very low (87-96% reduction in exocrine pancreatic dysfunction; mean FCT in healthy controls was 22.8 micrograms/g) (P < 0.0001). In contrast, KRDY and IDDM patients displayed 50-54% reduction in pancreatic acinar function (P < 0.001). Basal and stimulated C-peptide levels progressively fell in the 3 CCPT subsets (NGT: 0.23 and 0.46 > IGT: 0.14 and 0.29 > DM 0.10 and 0.14) (P < 0.01). CCPT patients exhibited pancreatic atrophy and ductal dilation (> 3 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

Anti tubercular treatment induced hepatotoxicity: does acetylator status matter?

Anti tubercular drug related hepatotoxicity is common. The mechanism of injury and factors predisposing to its development are not fully understood. Forty patients with anti tubercular drugs related hepatotoxicity were studied to see the clinical and biochemical profile of these patients and to find out the significance of acetylator phenotype in the development of hepatotoxicity. Mean age of patients with liver damage (37.82 +/- 10.0 years) was similar to those without liver damage (36.48 +/- 12.5 years). Pyrazinamide appeared to increase the hepatotoxicity of isoniazid and rifampicin. The percentage of rapid acetylators and slow acetylators among patients with hepatotoxicity (70% and 30% respectively) was similar to controls (66.6% rapid and 33.3% slow acetylators). Acetylator phenotype probably has no role in anti tubercular drugs induced hepatotoxicity.

Biliary strictures on ERCP: a study in northern India

Case records of 82 patients with biliary stricture diagnosed on endoscopic retrograde cholangiopancreatography (ERCP) during a 7-years period (1983-89) were analysed for its aetiology, clinical presentation, laboratory abnormalities and radiological characteristics. The aetiology was found to be benign in 59 and malignant in 23 patients. Forty seven percent of all strictures were post cholecystectomy strictures (PCS). Presence of mucosal irregularity and incomplete stricture were commoner with malignancy. Malignant biliary strictures (MBS) were commonly seen in males, occurred at older age, had short history, had higher alkaline phosphtase and serum bilirubin values when compared to patients with benign biliary strictures (BBS).

Ketosis resistant diabetes of the young: a profile of its exocrine and endocrine pancreatic dysfunction

A subset of insulin requiring diabetes in the young (IRDY) is ketosis resistant. Its pathogenesis and pathophysiology remain ill defined. The current study was done to evaluate the exocrine and endocrine dysfunction in ketosis resistant young diabetics. Fecal chymotrypsin (unit/G), basal & stimulated c-peptide levels (pmol/ml) and sonographic evaluation of the pancreas were done in 59 IRDY patients: 34 ketosis resistant (KR) and 24 ketosis prone (KP). Fecal chymotrypsin levels in KR (11.1 +/- 3.4) and KP (10.3 +/- 5.1) were lower than in controls (22.4 +/- 7.3) (P < 0.01). KR subjects had better endogenous insulin reserves than KP subjects: the basal and stimulated c-peptide levels in KR patients (0.12 & 0.17) were higher than in KP subjects (0.06 and 0.07) (P < 0.05). A strong correlation was noted between the exocrine and beta cell dysfunction in KR subjects (r = 0.7, P < 0.05). Pancreas was smaller in KR and KP patients than in controls (P < 0.05) on sonography. Thus the resistance to ketosis is a reflection of the better preserved beta cell reserves in the KR patients. Loss of the trophic effect of insulin and associated malnutrition is responsible for their exocrine dysfunction.

Nonsurgical drainage for biliary obstruction

Biliary obstruction is a common and potential fatal condition. Its pathological effects include depressed immunity, impaired phagocytic activity and reduced Kupffer cell function with consequent endotoxemia, septicemia and renal failure. Over the last decade however, non-surgical biliary drainage procedures performed with radiologic or endoscopic guidance emerged as alternative to surgical of therapy in many situations, particularly palliation of malignant strictures because of their lower morbidity and mortality rates. Endoscopic stent placement is preferred over percutaneous transhepatic catheter drainage in general. If endoscopic procedure is not possible or fails percutaneous transhepatic biliary drainage or combined radiological-endoscopic procedure should be employed. Surgery is currently reserved only for curative resection/palliative drainage in young and fit patients. Preoperative biliary drainage aimed at reducing post-operative morbidity and mortality is not universally accepted and needs further study. Benign strictures are increasingly being dilated non-surgically with temporary stenting, especially in patients with failed surgery, recurrent strictures, contraindication to surgery and pre-liver transplant strictures eg primary sclerosing cholangitis. A cohesive team consisting of a surgeon, a radiologist and an endoscopist is required to achieve the best possible results.

Toxic effects of chronic fluoride ingestion on the upper gastrointestinal tract

In a prospective case controlled study, we evaluated the adverse effects of long-term fluoride ingestion on the gastrointestinal tract. Ten patients with otosclerosis who were receiving sodium fluoride 30 mg/day for a period of 3-12 months, and 10 age- and sex-matched healthy volunteers were included. They were all evaluated clinically and subjected to a real time ultrasound examination, upper gastrointestinal endoscopy, and biopsies from the gastric antrum and duodenum. The biopsies were subjected to a rapid urease test as well as light and electron microscopic examinations. Ionic fluoride was estimated in the serum, urine, and drinking water using an ION 85 Ion Analyzer. Seven subjects (70%) ingesting fluoride had abdominal pain, vomiting, and nausea. Petechiae, erosions, and erythema were seen on endoscopy in all the subjects, but not in the controls. Histological examination of the gastric antral biopsy showed chronic atrophic gastritis in all the subjects but in only one (10%) healthy volunteer. Scanning electron microscopic examination showed "cracked-clay" appearance, scanty microvilli, surface abrasions, and desquamated epithelium in the subjects ingesting fluoride, but not in the controls. We conclude that long-term fluoride ingestion is associated with a high incidence of dyspeptic symptoms as well as histological and electron microscopic abnormalities.

Prevalence and clinical features of chronic pancreatitis in southern India

We have conducted a field study in India in the state of Kerala involving 28,567 inhabitants to determine the prevalence and clinical features of chronic pancreatitis of the tropics (CPT), an illness that is endemic in several regions of India. Selection criteria for the present study included: 1. Characteristic abdominal pain; 2. Evidence of diabetes mellitus; and 3. Evidence of malnutrition/malabsorption. A diagnosis of chronic calcific pancreatitis (CCP) was established by evidence of either 1, 2, or 3 plus X-ray evidence of pancreatic calculi. Diagnosis of noncalcifying chronic pancreatitis (NCCP) was established by 1, 2, or 3 plus an abnormal ultrasound of the pancreas and an abnormal bentiromide test. CPT was discovered among 36 individuals (prevalence 1:793). Strict entry criteria may have excluded additional cases. CPT was far advanced at the time of diagnosis in that 28 had evidence of calcification, 19 had diabetes mellitus, and 27 had an abnormal bentiromide test. The major differences from previous hospital-based studies were female predominance (male/female ratio, 1:1.8), onset of disease at an older age (mean 23.9 yr), and evidence of milder disease. We conclude that previous hospital-based reports that CPT is a severe illness with a male predominance may reflect greater access of seriously ill individuals in general and males in particular to medical care.

Spectrum of ulcerative colitis in north India

We analyzed retrospectively the characteristics of 87 patients with ulcerative colitis seen in a tertiary care center in north India. Ulcerative colitis was diagnosed on the basis of clinical features, sigmoidoscopy, rectal biopsy, and exclusion of microbiological causes of colitis. Severe clinical disease was seen in 53 (60%) patients that correlated with extensive colonic involvement (p < 0.001), severe changes on sigmoidoscopy (p < 0.001) and histology (p < 0.001), erythrocyte sedimentation rate (ESR) of > 30 mm for the first hour, and serum albumin of < 3 g/dl (p < 0.001). Remission of the disease was maintained on sulfasalazine in 18 (20.7%) patients, whereas 47 (54%) required steroids. Proctocolectomy with ileoanal anastomosis was done in 22 (25.3%) patients in whom there was poor response to medical treatment. Postoperative complications were seen in seven (31.8%) patients, and death occurred in four (18.1%) patients. Ulcerative colitis thus commonly presents as severe disease, with the majority of patients requiring surgery due to poor response to medical therapy. This pattern of disease as seen in an academic referral hospital in north India is virtually indistinguishable from that seen in similar centers in the West. However, in our setting, proctocolectomy and ileoanal anastomosis is cost-effective in patients unresponsive to, or unable to afford, drug treatment.

Unilateral congenital fibrosis syndrome presenting with hypertropia

A case of sporadic unilateral congenital fibrosis is described. The patient had the additional unusual features of primary position hypertropia and minimal ptosis.

Workplace toxic incident notification: results of a survey of 16 factory sites in western Sydney

Workers in the chemical industry are often employed where there is a potential for significant exposure to hazardous materials. Many of these events go unrecorded and are not notified to agencies charged with the responsibility of regulating the workplace. Therefore, a survey was conducted of factories covering a range of activities where poisonous chemicals are in use, aimed at proactively reviewing toxic incident reporting, including (i) underlying principles of notification, (ii) any relevant criteria used in the reporting of incidents, and (ii) compliance with existing legislation. Sixteen factories in the Western Sydney area were inspected by a government safety inspector over a 4-month period. Forty-eight employees were interviewed and data describing 46 exposure events were obtained covering a 12-month period. In all, 10 incidents were identified as significant exposure events, with 5 events (11% of total) at 5 different factories (31% of sites inspected) involving 8 workers (17% of workers interviewed) being definite breaches of statutory accident reporting requirements. The survey revealed a failure by employers to notify significant toxic exposure events due to reluctance or ignorance and or lack of clarity of occupational health and safety regulations. It also revealed that substantial numbers of workers are exposed to incidents involving poisonous materials, and that with this nonnotification, regulatory agencies are largely unaware of their magnitude.

Postoperative bile duct strictures: ultrasound and endoscopic retrograde cholangiopancreatography/percutaneous transhepatic cholangiography evaluation

This retrospective study was undertaken to assess the role of ultrasound (US) and to compare it with endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) in the evaluation of post-operative common bile duct (CBD) strictures. Seventy-four patients with postoperative CBD strictures were evaluated by ERCP and/or PTC. Of these, US scans were available in 52 patients. Ultrasound findings of CBD strictures were: proximal dilatation of CBD with smooth tapering stenosis (41%); abrupt cut off of CBD (18%); and echogenic nodule, without acoustic shadowing, in 16%. Of the remainder, mild proximal dilatation of the CBD was seen in 6%, and 19% of the patients had normal US scans.

Some toxicological issues in chemical safety and regulation in an Australian context

This article considers the potential effects on the human body of toxic hazardous substances in general, along with advanced methods of detecting short- and long-term effects of exposure with reference to the results of recent research. In addition to occupational exposure, other contributors to an individual's overall toxic exposure load including environmental and home and lifestyle exposures are also considered in detail. Toxicological information (from diverse sources) and an awareness of the limitations of our present state of knowledge of toxicology are concluded to be important factors in developing chemical safety and regulatory criteria. Although there is some debate concerning the adequacy of the exposure standard-setting process, TWA measures are capable of giving reliable indications of the efficacy of control measures and procedures. Electroencephalogram (EEG) activity reflecting stimulus attention and decision time, electromyography measuring nerve conduction velocities, reaction time, and neuropsychological performance-using batteries of psychometric tests, may all be effective indicators of exposure, interaction with other factors, and long-term effects of exposure.

Renal functions in obstructive jaundice: a pre and post operative assessment

Surgery in patients with surgical obstructive jaundice is known to be associated with increased risk of post-operative acute renal failure. A prospective study was carried out to evaluate the renal function in patients with obstructive jaundice. Renal functions of thirty two patients with jaundice secondary to mechanical obstruction of the biliary tract were evaluated pre-operatively and 7 days after surgical biliary decompression. Although no significant difference was seen in the mean values of pre and post operative renal function variables, two patients had overt renal failure, one with pre-operative cholangitis and acute tubular necrosis and another with carcinoma of the pancreas and postoperative acute renal failure. The overall satisfactory outcome in our obstructive jaundice patients may be related to pre-operative and intraoperative preparation with intravenous fluids and mannitol. It is concluded that patients with obstructive jaundice can be satisfactorily treated with special preoperative care including good hydration and mannitol therapy during anaesthesia and surgery.

Pancreatic abscess: is there a role for conservative therapy?

Pancreatic abscess is a serious complication of acute pancreatitis and non-operative management has been reported to carry a mortality of nearly 100%. We present five patients with pancreatic abscess, who were successfully treated with antibiotics alone. All 5 patients had acute pancreatitis followed by prolonged fever and development of an abdominal mass. The diagnosis was confirmed in each of them by a contrast enhanced CT scan and an ultrasound guided aspiration of pus from the pancreatic mass. The choice of antibiotics was decided by the culture reports in two cases and by Gram's staining in the remaining three patients. We attribute the success of antibiotic therapy in our patients to early diagnosis by CT scan and guided aspiration as well as the absence of any unfavourable risk factors. This study suggests that a select group of patients with pancreatic abscess may be managed conservatively with antibiotics.

Biliary peritonitis secondary to perforation of common bile duct: an unusual presentation of chronic calcific pancreatitis

Common bile duct perforation causing biliary peritonitis is an unusual entity and a pancreatic calculus causing this perforation is all the more rare, and to our knowledge has not been reported previously. Such an unusual presentation of chronic calcific pancreatitis is herein reported.

A prospective randomized study of the injurious effects of aspirin and naproxen on the gastroduodenal mucosa in patients with rheumatoid arthritis

A prospective double-blind randomized placebo-controlled study was conducted to compare the injurious effects of aspirin and naproxen on the gastroduodenal mucosa. Patients with rheumatoid arthritis attending the immunology clinic of a tertiary care center were included in the study. Ninety consecutive patients were randomized to receive aspirin, naproxen, or placebo. Clinical evaluation was done every 2 wk. Upper gastrointestinal endoscopy, biopsies from the gastric antrum and duodenum for histological examination, and Helicobacter pylori studies were done at entry and after 2 months. The number of patients with dyspeptic symptoms was similar in the aspirin (12) and naproxen (9) groups. In both cases, however, it was higher (p less than 0.01) than in the placebo group (none). Naproxen was associated with a higher score of endoscopic abnormalities in the gastric body (0.6 +/- 1.3) than aspirin (0.2 +/- 0.6) or placebo (0.03 +/- 0.18). H. pylori was present in a similar proportion of patients in the three groups (33-43%). A greater fall in hemoglobin was observed with aspirin (0.35 +/- 0.48 g%) and naproxen (0.44 +/- 0.53 g%) than with placebo (0.09 +/- 0.4 g%). The present study suggests that aspirin and naproxen produce a similar degree of injury to the gastroduodenal mucosa.

Sodium benzoate in the treatment of acute hepatic encephalopathy: a double-blind randomized trial

A prospective randomized double-blind study was conducted to evaluate the efficacy of sodium benzoate in the treatment of acute portal-systemic encephalopathy. Seventy-four consecutive patients with cirrhosis or surgical portasystemic anastomosis and hepatic encephalopathy of less than 7 days duration were randomized to receive lactulose (dose adjusted for 2 or 3 semiformed stools/day) or sodium benzoate (5 gm twice daily). Assessment of response included mental status, asterixis, arterial ammonia level, electroencephalogram and number-connection test. Each was given a score between 0 and 4+. A portal-systemic encephalopathy index was calculated with these scores. Visual, auditory and somatosensory evoked potentials and a battery of psychometric tests for intelligence and memory were also performed to assess improvement. Thirty-eight patients received sodium benzoate; 36 took lactulose. Thirty patients (80%) receiving sodium benzoate and 29 (81%) receiving lactulose recovered; the remaining patients died. Improvement in portal-systemic encephalopathy parameters occurred in both treatment groups and was similar (p greater than 0.1). Electroencephalogram and evoked potentials were not as helpful as mental status in assessing of recovery. Psychometric test scores remained abnormal after recovery of mental status (21 to 42 days) and were probably too sensitive for monitoring of these patients. The incidence of side effects was similar in the two treatment groups. The cost of lactulose for one course of therapy was 30 times that of sodium benzoate. We conclude that sodium benzoate is a safe and effective alternative to lactulose in the treatment of acute portasystemic encephalopathy.

Fluoride as a possible aetiological factor in non-ulcer dyspepsia

A prospective case controlled study was conducted to evaluate the role of fluoride as a possible aetiological factor for non-ulcer dyspepsia (NUD). Twenty patients with NUD and 10 age and sex matched healthy controls were subjected to clinical evaluation, upper gastrointestinal endoscopy and biopsies from the gastric antrum and duodenum. The antral and duodenal mucosa was subjected to a rapid urease test for Helicobacter pylori and histological and electron microscopic examinations. Fluoride levels in the drinking water, serum and urine were estimated using a ION 85 ion-analyser. These levels were significantly higher in patients with NUD than in controls (P less than 0.05). Histological abnormalities in the antral and duodenal mucosa were seen in 14 patients (70%) with NUD and 1 control subject (10%) (P less than 0.05). Electron microscopic abnormalities in the mucosal cells were seen in all patients with NUD but in none of the controls (P less than 0.01). The fluoride levels in serum and urine correlated with the symptoms, histological and electron microscopic abnormalities (P less than 0.05). It was concluded that chronic exposure to fluoride may result in NUD and should be considered in patients where other known cause of dyspepsia have been excluded.

Gastrointestinal endoscope disinfection practices in India: results of a national survey

A questionnaire was sent to 435 endoscopy centers in the country to obtain information regarding current endoscopic disinfection practices. Of these, 133 (30.6%) centers responded. Adequate disinfection (a minimum exposure to 1% glutaraldehyde for 2 minutes) before the start of endoscopy sessions and between procedures was practised in 61 (46%) and 45 (34%) centers respectively. The proportion of centers practising adequate disinfection was similar among those performing < 1500 and > 1500 endoscopies/year (50% vs 36%; p = ns). Twenty two (17%) centers used some additional precautions in patients with hepatitis B virus infection or immunocompromised states. Two (1.5%) of the 133 centers performing upper GI endoscopies and eight (18%) of the 44 centers performing ERCP examinations reported occurrence of infections following these procedures. Allergic reactions to disinfectants were reported by five (4%) centers. We conclude that only about a third of the gastroenterology centers in the country are practising adequate endoscope disinfection routinely.

A study of Helicobacter pylori in north Indian subjects with non-ulcer dyspepsia

A prospective case control study was conducted in 50 patients with non-ulcer dyspepsia (NUD) and 10 age and sex matched controls to determine the prevalence of Helicobacter pylori in patients with NUD and to correlate symptoms, histology and presence of H pylori in gastric biopsies. Endoscopic biopsies from antrum and fundus were subjected to urease test and histological examination. On histology, H pylori was identified in 27 (54%) NUD patients and in one of 10 controls. Urease test was positive in 31 (62%) antral and 21 (42%) fundal biopsies in patients with NUD and in only one (10%) of 10 antral biopsies in the control group. On histology, gastritis was present in the antrum in 46 (92%) NUD patients and in the fundus in 40 (80%) cases; of these, 27 (54%) and 15 (30%) had H pylori in antral and fundal biopsies respectively. The severity of antral gastritis correlated with the density of H pylori (p < 0.05).