Multidisciplinary consensus statement on the clinical management of patients with pancreatic cancer

Pancreatic cancer (PC) remains one of the most aggressive tumors with an increasing incidence rate and reduced survival. Although surgical resection is the only potentially curative treatment for PC, only 15–20% of patients are resectable at diagnosis. To select the most appropriate treatment and thus improve outcomes, the diagnostic and therapeutic strategy for each patient with PC should be discussed within a multidisciplinary expert team. Clinical decision-making should be evidence-based, considering the staging of the tumor, the performance status and preferences of the patient. The aim of this guideline is to provide practical and evidence-based recommendations for the management of PC.

Platypnea-orthodeoxia syndrome: Importance of patient position for correct diagnosis at the time of (99m)Tc-MAA injection

A 65-year-old male presented with unexplained hypoxia that became exacerbated by an upright posture (platypnea-orthodeoxia syndrome) secondary to hepatopulmonary syndrome (HPS). A (99m)Tc-macroaggregated albumin pulmonary perfusion scan revealed a right to left shunt of 29% in the sitting position, which had not been previously detected when the radiotracer injection was performed with the patient in supine position, nor was it diagnosed using another non-invasive imaging method (transthoracic contrast echocardiography and angio-CT). A transesophageal echocardiography was contraindicated due to the presence of esophageal varices. The administration of the radiopharmaceutical in sitting position for the study of the pulmonary perfusion allowed us to confirm the presence of the shunt and consider the patient a candidate for liver transplantation.

A Spanish multicenter study to estimate the prevalence and incidence of chronic pancreatitis and its complications

BACKGROUND AND OBJECTIVE

No nation-wide epidemiological study on the incidence and prevalence of chronic pancreatitis (CP) had been thus far carried out in Spain. Our goal is to estimate the prevalence and incidence of CP, as well as to determine the diagnostic and therapeutic criteria used in Spanish pancreas units.

METHODS

An observational, descriptive study of hospital pancreas units in Spain. CP-related epidemiology, etiology, manifestations, diagnostic tests, functional complications, and treatments were all assessed using a structured questionnaire. Overall results were estimated by weighting cases in each site.

RESULTS

Information was collected from six pancreas units with a sample frame of 1,900,751 inhabitants. Overall prevalence was 49.3 cases per 105 population (95 % CI, 46 to 52) and incidence was 5.5 cases per 105 inhabitant-years (95 % CI, 5.4 to 5.6). Most common etiologies included tobacco and alcoholism, which were associated with three in every four cases. The most prevalent symptoms were recurring pain (48.8 %) and chronic abdominal pain (30.6 %). The most widely used diagnostic method was echoendoscopy (79.8 %), CT (computerized tomography) (58.7 %), and MRI (magnetic resonance imaging)/MRCP (magnetic resonance cholangiopancreatography) (55.9 %). Most prevalent morphologic findings included calcifications (35 %) and pseudocysts (27 %). Exocrine (38.8 %) and endocrine (35.2 %) pancreatic insufficiency had both a similar frequency. Treatments used were rather heterogeneous among sites, with enzyme replacement therapy (40.7 %) and insulin (30.9 %) being most commonly used.

CONCLUSIONS

Pancreas units amass a significant number of both prevalent and incident CP cases. Patients seen in these units share a similar typology, and differences between units are greater regarding diagnostic and therapeutic strategies.

Percutaneous endoscopic suturing is an alternative treatment for persistent gastrocutaneous post-PEG fistula

Persistent gastrocutaneous fistula after the removal of a gastrostomy tube is an unusual complication associated with percutaneous endoscopic gastrostomy (PEG). Surgical closure has been usually the treatment of choice. Several endoscopic methods have been previously attempted to close the fistula, usually with poor results. We report a successful case of percutaneous endoscopic suturing of a persistent gastrocutaneous post-PEG fistula, using a monofilament absorbable suture. A biopsy forceps was used to deepithelialize both ends of the fistulous tract to promote granulation tissue formation. The gastrocutaneous fistula closed completely after the procedure and there were no complications during the follow-up.

NOD2, CD14 and TLR4 mutations do not influence response to adalimumab in patients with Crohn's disease: a preliminary report

INTRODUCTION

Adalimumab is a recombinant fully-human monoclonal immunoglobulin (IgG1) antibody utilized in the treatment of Crohn's disease. Unfortunately no clinical or genetic markers exist to predict response to anti-tumor necrosis factor-alpha (TNF) therapy. The aim of this study was to evaluate the association between selected genes involved in cytokine regulation and response to adalimumab treatment in Crohn's disease.

METHODS

twenty-four patients with Crohn's disease either naïve (n = 8) or had lost response or were unable to tolerate the chimeric anti-TNF antibody infliximab (n=16) were enrolled in the study. Patients were genotyped for main polymorphisms in NOD2, CD14 and TLR4 genes. Response to adalimumab treatment was defined as a decrease of Crohn's disease activity index of at least 100 points or a closure of at least 50% of fistulas in case of fistulizing Crohn's disease.

RESULTS

overall, 75% of patients did respond to treatment. However, no statistically significant association was found between any of the genotypes and the response to adalimumab.

CONCLUSIONS

In our small study group no association between the studied polymorphisms and response to adalimumab was apparent. Systematic studies to search for genetic markers of response to anti-TNF therapy are necessary.

Gastrointestinal stromal tumors (GISTs) of the colon

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal (GI) tract. Although they may arise anywhere of GI tract, colonic presentation is infrequent. We report 2 new cases of colonic GISTs localized at descending and sigmoid colon. Endoscopic biopsies were diagnostic for GISTs and no distant metastasis were observed. Both cases underwent resective surgery as the only treatment. No recurrence was observed during the follow-up period. In this clinical note we review the diagnosis, management and therapeutical options in colonic GISTs, according to literature. KIT immunoreactivity is the base for diagnosis. Risk of malignancy is based on the primary tumor diameter and the mitotic count. Anatomic localization is not an independent prognostic factor. Surgery is the standard treatment for localized primary disease and imatinib is indicated if metastatic or unresectable GISTs.

NOD2/CARD15: geographic differences in the Spanish population and clinical applications in Crohn's disease

Crohn's disease (CD) is a genetically complex disease in which both genetic susceptibility and environmental factors play key roles in the development of the disorder. NOD2/CARD15 mutations are associated with CD. NOD2 encodes for a protein that is an intracellular receptor for a bacterial product (muramyl dipeptide), though the exact functional consequences of these mutations remain the subject of debate. NOD2/CARD15 mutations are associated with ileal CD, with stricturing behavior, and possibly with a more complicated course of CD. NOD2/CARD15 mutations associated with CD have demonstrated heterogeneity across ethnicities and populations throughout the world, with regional variations across Europe and Spain. However, "NOD2/CARD15 testing" is not yet ready for use in the clinical setting. One of the reasons is that we know that these genetic variants increase the risk of disease only marginally, and many healthy individuals carry the risk alleles, at present it is not recommended to screen first-degree relatives, because we do not have the ability to prevent the disease at the present time.

Psychological impact of Crohn's disease on patients in remission: anxiety and depression risks

BACKGROUND

the role of anxiety and depression in CD patients in remission has been poorly investigated.

OBJECTIVE

the aim of the study was to evaluate the frequency of anxiety and depression symptoms in CD patients in remission, and potential factors influencing the development of these symptoms.

METHODS

CD patients older than 18 years in remission for at least 6 months before study entry were included. CD remission was defined as a Crohn s Disease Activity Index (CDAI) < 150 points together with C-reactive protein < 5 mg/L. A demographic questionnaire was filled in, and all patients were clinically classified. The therapy maintaining remission was also recorded. A Hospital Anxiety and Depression scale (HAD) was administered to all patients. Results are shown as OR and 95% CI, and analyzed by logistic regression.

RESULTS

92 consecutive patients were included (48 male, mean age 37 years, range from 18 to 71 years). One patient failed to correctly fill in the questionnaire. Anxiety and depression symptoms were present in 36 (39%) and 22 (24%) patients, respectively. Infliximab therapy was the only factor associated with anxiety (OR = 3.11; 95% CI: 1.03-9.43; p < 0.05). In contrast, the presence of depressive symptoms is less frequent in patients under infliximab therapy (OR = 0.16; 95% CI: 0.02-0.97; p < 0.05).

CONCLUSIONS

despite clinical remission, an important number of CD patients present with anxiety or depressive symptoms. Infliximab therapy in CD patients is associated to more anxiety but fewer depressive symptoms. CD patients in remission would probably benefit from psychological support.

Association of NOD2/CARD15 mutations with previous surgical procedures in Crohn's disease

OBJECTIVE

The aim of this study is to assess the importance of NOD2/CARD15 gene mutations as prognostic factors for surgical indications in Crohn's disease. PATIENTS AND EXPERIMENTAL DESIGN: A total of 165 Crohn s disease patients were studied, considering previous surgery related to Crohn's disease. We analyzed for previous surgery in global procedures as well as separately for the two main surgical indications: ileal resection and fistula treatment. The need for appendectomy was also studied. All patients were genotyped for the three CARD15 mutations, and association studies were developed using Chi-square statistics and Fisher's exact test whenever appropriate.

RESULTS

Carriers of the G908R or 1007fs mutation needed surgery more frequently, both for ileal resection and fistula repair. In contrast, appendectomy was not associated with CARD15 mutations.

CONCLUSIONS

As previously reported in this population, the R702W mutation does influence parameters of disease or need of surgery. The need for Crohn's disease-related surgery is higher in carriers of the G908R or 1007fs CARD15 mutation in the Galician population. Nevertheless, the frequency of these mutations does not allow their use to predict the course of disease.

Effect of the administration schedule on the therapeutic efficacy of oral pancreatic enzyme supplements in patients with exocrine pancreatic insufficiency: a randomized, three-way crossover study

BACKGROUND

Oral pancreatic enzyme supplements should be properly administered in order to ensure an adequate gastric mixing with the food and simultaneous gastric emptying with the chyme.

AIM

To evaluate, in a prospective, randomized, open, comparative, three-way, crossover study, the effect of the administration schedule on the efficacy of oral pancreatic enzymes for the treatment of exocrine pancreatic insufficiency.

METHODS

Twenty-four consecutive chronic pancreatitis patients with maldigestion secondary to exocrine pancreatic insufficiency were treated with 40 000 U lipase in the form of capsules containing enteric-coated mini-microspheres. Capsules were taken just before meals (schedule A), just after meals (schedule B) or distributed along with meals (schedule C) for three consecutive 1-week crossover periods in a randomized order. Fat digestion before and during the three treatment periods was evaluated by an optimized mixed (13)C-triglyceride breath test.

RESULTS

Before therapy, the (13)CO(2) recovery in the breath test was 23.8 +/- 15.8% (normal >58.0%). During therapy, the (13)CO(2) recovery tended to be higher when capsules were taken along with meals ((13)CO(2) recovery 61.4 +/- 21.4%) or just after meals ((13)CO(2) recovery 60.6 +/- 21.8%) than when taken just before meals ((13)CO(2) recovery 53.9 +/- 20.3%). The percentage of patients who normalized fat digestion under therapy was 50, 54 and 63% with schedules A, B and C respectively.

CONCLUSIONS

The efficacy of pancreatic enzyme supplements for the treatment of exocrine pancreatic insufficiency may be optimized by administration during or after meals.

[Comparison between two 13C-urea breath tests for the diagnosis of Helicobacter pylori infection: isotope ratio mass spectrometer versus infrared spectrometer]

OBJECTIVES

To compare the accuracy of the breath test using the isotope ratio mass spectrometer (IRMS) versus the nondispersive isotope-selective infrared spectrometer (NDIRS) in the diagnosis of Helicobacter pylori infection.

METHOD

Multicenter study in 4 Spanish hospitals. One group of dyspeptic patients who had not undergone prior eradication therapy and another group of patients with gastric ulcer or gastrointestinal bleeding due to gastroduodenal ulcer receiving H. pylori eradication therapy were included in the study. A reference standard based on histology and the rapid urease test was used. The breast test (TAU-KIT, Isomed S.L., Madrid, Spain) was performed with citric acid and 100 mg of 13C-urea. Samples of expired air were collected in tubes and bags for reading with the IRMS (ABCA, PDZ, Crewe, Manchester, England) and the NDIRS (UBiT-IR200, Otsuka Electronics, Co, Osaka, Japan), respectively. The endoscopist, pathologist and person responsible for reading the urease test and both breath tests were blinded to the results of the other diagnostic methods.

RESULTS

Forty-one patients were included. The prevalence of H. pylori was 26%. No differences were found on comparing the mean values obtained with the IRMS and the NDIRS: 13 (standard deviation) (24) and 14 (25) delta units, respectively. The area under the ROC curve for the IRMS and the NDIRS was 0.96. The diagnostic accuracy for the best cut-off point with the IRMS and the NDIRS was, respectively: sensitivity (90 and 100%), specificity (96 and 89%), positive predictive value (90 and 77%), negative predictive value (96 and 100%), + likelihaod ratio (25 and 9.3) and (0.1 and 0). A close correlation was found between the values of the IRMS and those of the NDIRS (lineal regression equation, Y = 1.1 + 1.004. X; r = 0.97).

CONCLUSION

Both the spectrometers used to evaluate the breath test, the IRMS and the NDIRS, offer a high degree of accuracy in the diagnosis of H. pylori infection.

Validation of the 13c-urea breath test for the initial diagnosis of helicobacter pylori infection and to confirm eradication after treatment

OBJECTIVES

the breath test with 13C-urea (UBT) is a method widely used in Spain, but its diagnostic accuracy has not been evaluated in a clinical trial until now. Our objective was to validate the UBT (TAU-KIT) both as an initial diagnostic method for the detection of H. pylori infection and as a method to confirm eradication.

METHODS

a multi-centre study in 7 Spanish hospitals was performed. A group of dyspeptic patients who had not previously received eradication treatment was included, and a second group of patients with gastric ulcer or upper gastrointestinal bleeding due to peptic ulcer was also included (eradication of H. pylori was confirmed 6 to 8 weeks after treatment completion with omeprazole, clarithromycin and amoxycillin). In both groups an endoscopy was performed with biopsies for histology and rapid urease test. Patients were considered infected if both tests yielded positive results, and not infected when both tests were negative. The UBT 13C-urea (TAU-KIT, Isomed S.L., Madrid, Spain) was performed with citric acid and 100 mg of 13C-urea. The pathologist and persons responsible for endoscopy, urease test and UBT were all unaware of the results from the other diagnostic methods.

RESULTS

in the pre-treatment group (36 patients) the prevalence of H. pylori was 72%, the area under the ROC curve for the diagnosis of infection with the UBT was 0.99, and the best cut-off point was 5 units, with the following results: sensitivity= 96% (95% CI = 81-99%), specificity= 100% (69-100%), positive predictive value (PPV) = 100% (87-100%), negative predictive value (NPV) = 92% (59-100%), likelihood ratio (LR) + = infinity, and LR- = 0.04. In the post-treatment group (85 patients) the prevalence of H. pylori was 16%, the area under the ROC curve was 0.99, and the best cut point was 4.6, with the following results: sensitivity= 100% (77-100%), specificity = 97% (90-99%), PPV = 88% (62-98%), NPV = 100% (95-100%), LR+ = 35, and LR- = 0.

CONCLUSION

UBT provides excellent accuracy both for the initial diagnosis of H. pylori infection and to confirm eradication after treatment.

Targeting the abnormalities of gastroduodenal functions in functional dyspepsia

The current definition of functional dyspepsia changes the previous concept of absence of organic disease to the presence of a functional alteration of the upper gastrointestinal tract. From a theoretical point of view, the alteration of any major gastrointestinal function may induce dyspeptic symptoms. However, both asymptomatic subjects with some gastrointestinal functional alteration and dyspeptic patients without a demonstrable dysfunction are not unusual. This may be explained at least in part by the more recent concept of visceral sensitivity. The potential role of acid secretion in the pathogenesis of functional dyspepsia as well as the positive effect of antisecretory drugs in a proportion of patients may be based on an increased gastric acid secretion and duodenal acid overload, a hypersensitivity to acid and/or the development of acid-mediated gastrointestinal motor abnormalities. Helicobacter pylori infection may play a role in this context. Both interdigestive and postprandial gastrointestinal motility, mainly a delayed gastric emptying and an altered intragastric distribution of nutrients, have been described to be disturbed in up to half of the patients with functional dyspepsia. This may also be an explanation for the high frequency of intestinal bacterial overgrowth in these patients. Most probably, visceral hypersensitivity should be present for motor alterations to induce symptoms. This is the basis for future development of new drugs in the management of this functional syndrome. The role of H. pylori in the pathogenesis of functional dyspepsia is a matter of discussion, but a proportion of patients benefit from eradication therapy and, therefore this therapeutic approach should be taken into account.

Update in the therapeutic management of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a remarkably frequent disorder that leads to relevant impairment in patients' quality of life. Four mechanisms are involved in the pathogenesis of IBS: altered intestinal motility; increased visceral sensitivity; disturbed intestinal reflexes (intrinsic and extrinsic), and psychological disorders. The close relationship between the central nervous system and the enteric nervous system (the brain-gut axis) is the basis of the actual research on IBS therapy. It is conceivable that in the near future a better understanding of IBS pathophysiology will help us to tailor treatment for different IBS patients. At the moment, the subclassification of the diverse patterns of symptomatology allows the adjustment of treatments for IBS according to the clinical predominance of each patient. Dietary modifications like fiber supplementation, antidiarrheal agents and antispasmodic drugs are the basis of the current treatment of IBS and depend on the predominant symptom (constipation, diarrhea or pain, respectively). If severe pain is present, antidepressant agents are an appropriate alternative. However, the scientific evidence supporting this current therapeutic approach is limited. Visceral analgesics and serotonin agonists and antagonists may play an important therapeutic role in the near future. However, it is not likely that one single treatment will help every IBS patient and many of them will need a more complex approach with multidisciplinary therapy (diet, psychotherapy, medications).

Effect of Helicobacter pylori infection on gastrointestinal motility, pancreatic secretion and hormone release in asymptomatic humans

BACKGROUND

Helicobacter pylori infection is associated with complex alterations of the gastric physiology in patients with ulcer disease or functional dyspepsia. We aimed at evaluating whether H. pylori infection is accompanied by changes in interdigestive and postprandial gastrointestinal motility, exocrine pancreatic secretion or hormone release in asymptomatic subjects.

METHODS

Nineteen healthy men (age range 26-35 years) were studied after 12 h fasting. Motor activity was recorded for a complete motor migrating complex cycle and two postprandial hours. Pancreatic enzyme secretion was evaluated using a standard duodenal perfusion technique. Plasma concentrations of gastrin, PP and motilin were determined at 15-min intervals. H. pylori infection was proved by serology and 13C-urea breath test.

RESULTS

Eight subjects (42%) were H. pylori positive. Interdigestive and postprandial gastrointestinal motility were similar in H. pylori positive and negative subjects. Interdigestive pancreatic secretion was increased in H. pylori positive subjects (P < 0.05). Postprandial pancreatic secretion tended also to be higher in H. pylori positive subjects. H. pylori infection was associated with an increased postprandial release of gastrin (P < 0.05) as well as with a slight increase of interdigestive gastrin release. The release of PP and motilin, as well as the interdigestive coordination between gastrointestinal motility, pancreatic secretion and hormone release, was not altered by H. pylori infection.

CONCLUSIONS

H. pylori infection in asymptomatic subjects is associated with changes not only in gastric physiology but also in pancreatic function. This first reported link between H. pylori and the pancreas could have pathophysiological implications in pancreatic diseases and therefore deserves further study.

Effect of cisapride on gastric sensitivity to distension, gastric compliance and duodeno-gastric reflexes in healthy humans

BACKGROUND AND AIMS

Visceral hypersensitivity and impaired gastric relaxation after the ingestion of a meal are frequent features in patients with functional dyspepsia. Cisapride improves dyspeptic symptoms. The study aims to evaluate whether cisapride influences gastric sensitivity to distension as well as gastric compliance and duodenogastric reflexes.

PATIENTS AND METHODS

Eight healthy males were studied on two different days, each after 7 days' treatment either with placebo or cisapride 10 mg qid in randomized order. A spherical bag connected to a barostat was placed in the gastric fundus and an 8-lumen manometric catheter was positioned with 4 side holes in antrum and 4 in duodenum. During a phase II of the migrating motor complex, the intragastric bag was inflated at a constant pressure 1 mm Hg above the intra-abdominal pressure and the gastric volume was measured during intraduodenal infusion of lipids and citric acid at different rates. Once the stomach returned to the basal volume, the bag was distended according to two different protocols until subjects reported discomfort. Antroduodenal motility was measured throughout the study.

RESULTS

Intraduodenal infusion of lipids and citric acid caused relaxation of gastric fundus. Relaxation was similar for lipids and acid (203 +/- 30 vs 199 +/- 43 ml), and was not influenced by cisapride and infusion rate. Cisapride did not influence gastric sensitivity to distension (10 +/- 1.5 vs 9.7 +/- 1.3 mm Hg) and gastric compliance (52.7 +/- 1.2 vs 49.8 +/- 1.8 ml/mm Hg). The antral motor index significantly decreased following infusion of acid and lipids with placebo but not with cisapride.

CONCLUSIONS

Cisapride inhibits the physiological duodenoantral reflexes but does not influence either the mechanical properties of the gastric fundus nor the gastric sensitivity to distension.

Comparison of two tubeless function tests in the assessment of mild-to-moderate exocrine pancreatic insufficiency

BACKGROUND

Faecal elastase 1 (FE1) and the pancreolauryl test (PLT) are widely used for the non-invasive diagnosis of exocrine pancreatic insufficiency (EPI). Whether one of these two tests is superior for the detection of mild-to-moderate EPI is the subject of controversy. The aim of this study was to compare the diagnostic performance of the PLT and FE1 for the detection of EPI in patients with chronic pancreatitis.

METHODS

Forty consecutive patients (27 males, 13 females, 23-72 years) with chronic pancreatitis based on imaging procedures (computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasound) were admitted to the study. A secretin-caerulein test (SCT) was performed after an overnight fast by giving secretin (1 U/kg/h) and caerulein (100 ng/kg/h) intravenously over 90 min. Duodenal contents were aspirated at 15 min intervals and analysed for pH, bicarbonate, amylase, lipase and elastase. EPI was graded on the basis of the results of the SCT as absent, mild, moderate or severe. A serum PLT was performed in accordance with a modified protocol previously described. A commercial ELISA was used for determination of FE1. The cut-off values were > or = 4.5 mg/l for PLT and > or = 200 microg/g for FE1. and 13 severe) on the basis of the results of the SCT. The sensitivity of the PLT for diagnosing EPI of all degrees of severity was 82% (27/33), compared with 50% for FE1 (16/ 33). In patients with severe EPI, the PLT was abnormal in 100% (13/13) and FE1 was abnormal in 85% (11/13) of the cases. The sensitivity decreases for both tests in the group of mild/moderate EPI (PLT 70% (14/20), FE1 35% (7/20)). In all seven patients with normal exocrine pancreatic function, both PLT and FE1 were also normal.

CONCLUSIONS

The PLT is more sensitive than FE1 for the diagnosis of mild-to-moderate EPI, and is therefore more appropriate for completing the staging of chronic pancreatitis.

Validity of a modified 13C-urea breath test for pre- and posttreatment diagnosis of Helicobacter pylori infection in the routine clinical setting

OBJECTIVE

Citric acid meets the criteria of an optimal test drink for the 13C-urea breath test (13C-UBT) because it permits rapid, high level recovery of the 13C administered. In a previous study we reported that administration of 13C-urea dissolved in a citric acid solution provides results similar to those obtained with standard administration of the substrate 10 min after the test drink. The aim of this study was to evaluate the accuracy of this modified 13C-UBT for both primary and posttreatment diagnosis of Helicobacter pylori (H. pylori) infection in a large patient population in clinical practice.

METHODS

The 13C-UBT was performed in 553 patients with dyspeptic symptoms by giving them 75 mg of 13C-urea either 10 min after administration of 200 ml of a test drink comprising 0.1 mol/L citric acid solution (protocol 1, n = 320) or dissolved in the same amount of this test drink (protocol 2, n = 233). All patients underwent an upper gastrointestinal endoscopy and the H. pylori-status was assessed by histology, rapid urease test, and culture. Sixty patients with proven H. pylori infection were reinvestigated by both endoscopy and 13C-UBT (protocol 2) 4 wk after completing eradication therapy.

RESULTS

The accuracy of the two test protocols in the pretreatment diagnosis of H. pylori infection (95.6% and 96.6%), as well as of the modified 13C-UBT in the posttreatment evaluation of the infection (98.3%) was similar. More meaningful are the high PPV (>96%) and NPV (>93%) of the 13C-UBT under pre- and posttreatment conditions.

CONCLUSIONS

The administration of 13C-urea dissolved in a citric acid solution simplifies the 13C-UBT, while preserving the high accuracy in the diagnosis of H. pylori infection. This modified 13C-UBT has equal accuracy in the pre- and the posttreatment situations.

Citric acid or orange juice for the 13C-urea breath test: the impact of pH and gastric emptying

BACKGROUND

There is an ongoing debate about the optimal test drink to be used in the 13C-urea breath test (13C-UBT). We recently reported that a citric acid solution is the optimal test drink in the 13C-UBT, because it provides a high 13CO2 recovery and the excellent accuracy of the test appears optimal compared to other test meals. Orange juice, because of a better taste, is also propagated as a test drink in the 13C-UBT.

AIM

To compare the diagnostic accuracy of the 13C-UBT with either orange juice or citric acid solution as a test drink. Furthermore, the effect of these test drinks on the gastric emptying rate was determined.

METHODS

H. pylori status was assessed by histology, rapid urease test and culture in 50 consecutive dyspeptic patients. A 13C-UBT was performed on two consecutive days by giving 75 mg of 13C-urea randomly dissolved in 200 mL 0.1 M citric acid solution or 200 mL orange juice. The 13CO2/12CO2 ratio was measured in breath samples taken before and 15, 30, 45 and 60 min after administration of the test drink. The gastric emptying rate of orange juice and citric acid solution was compared to that of water in 10 healthy subjects on three consecutive days by means of a 13C-sodium acetate breath test; 50 mg of 13C-sodium acetate was dissolved in 200 mL of each solution and breath samples were collected before and every 10 min for 90 min after administration of the test drink.

RESULTS

Twenty-six out of 50 patients (52%) were infected with H. pylori. Significantly higher values over baseline (35.7+/-5.2 per thousand vs. 23.2+/-3.4 per thousand, P<0.001) and higher area under the curve (1507+/-198 vs. 927+/-128, P<0.001) were observed in H. pylori-positive patients when citric acid solution was administered compared with orange juice. Sensitivity of the 13C-UBT was 100% when citric acid was used as a test drink and 88% with orange juice. Specificity was 100% with both test drinks. Gastric emptying of citric acid solution (t1/2 = 60.9+/-3.5 min) was significantly slower than that of orange juice (t1/2 = 49.7+/-3.1 min, P<0.001).

CONCLUSION

13C-UBT loses diagnostic accuracy when orange juice instead of citric acid is used as a test drink. The faster gastric emptying of orange juice might be responsible for the lower diagnostic accuracy of the 13C-UBT.

Optimized serum pancreolauryl test for differentiating patients with and without chronic pancreatitis

The serum pancreolauryl test has limited sensitivity for detecting mild pancreatic insufficiency. The aim of this study was to optimize the serum pancreolauryl test so as to increase the probability of positive results in patients with chronic pancreatitis. The study had three parts. First, the sampling time was optimized by analyzing retrospectively the frequency of fluorescein peaks at different times from 0 to 240 min in 560 consecutive patients. Second, the calculation of serum fluorescein concentrations by means of a standard calibration factor was prospectively compared in 271 consecutive patients with a modification involving a specimen-specific calibration factor for each patient. Third, the clinical utility of the intravenous injection of secretin before ingestion of the test meal was prospectively evaluated in a further 32 patients. As a result, the optimized serum pancreolauryl test developed differs from the former version of the test in utilizing intravenous administration of secretin before the test meal, calculation of serum fluorescein based on specimen-specific calibration factors, and blood samples taken only at 0 (basal), 120, 150, 180, and 240 min. This optimized pancreolauryl test was abnormal more frequently in patients with chronic pancreatitis than was the formerly used test, especially for cases of mild and moderate disease.

13C-urea breath test for the diagnosis of Helicobacter pylori infection. A further simplification for clinical practice

BACKGROUND

The 13C-urea breath test is the most accurate noninvasive method for the diagnosis of Helicobacter pylori infection. The oral administration of citric acid solution as test drink 10 min before administration of 13C-urea appears to be the most valuable test procedure hitherto reported. To simplify the test for clinical routine, we evaluated in a prospective, randomized, crossover study the accuracy of a new modification that consists in giving the 13C-urea dissolved in the test drink.

METHODS

Forty dyspeptic patients were studied. H. pylori status was assessed by histology, rapid urease test, and culture. A 13C-urea breath test was performed on 2 consecutive days by giving 200 ml 0.1N citric acid solution either 10 min previous to (protocol 1) or simultaneously with (protocol 2) the administration of 75 mg 13C-urea in randomized order. The 13CO2/12CO2 ratio was measured in breath samples taken before and 10, 20, 30, 45, and 60 min after administration of 13C-urea.

RESULTS

Twenty patients were H. pylori-positive. In these subjects maximal delta values (28.1 per thousand (21.4-34.9) versus 30.6 per thousand (22.8-38.4)), expired cumulative amount of 13C (9.3% (6.9-11.7) versus 10.2% (7.4-12.9)), and time to maximal delta value (33 min (26-39) versus 35 min (29-42)) obtained by applying test protocols 1 and 2, respectively, were similar. Both test protocols provided negative results in all H. pylori-negative subjects. The 13C-urea was stable in citric acid solution at room temperature for at least 2 weeks.

CONCLUSIONS

The 13C-urea breath test for the diagnosis of H. pylori infection can be simplified by giving the substrate dissolved in the test drink. This modification is not associated with a loss of diagnostic accuracy.

Independent cycles of exocrine pancreatic secretion, hormones and gastroduodenal motility in healthy fasting humans: reassessment of a complex partnership

BACKGROUND

Interdigestive pancreatic secretion cycles in close association with the phases of the migrating motor complex (MMC) and release of regulatory hormones. The extrinsically denervated pancreas exhibits an intrinsic cyclic rhythm. We hypothesized that this intrinsic rhythm is normally present in the intact human pancreas.

METHODS

19 healthy males (age range 26-35 years) were studied after 12 h fasting. A manometry catheter was positioned with four pressure ports in the antrum and three in the duodenum, and motility was recorded for a complete MMC cycle or 5 h. Duodenal aspirates were sampled at 15-min intervals, and immediately analysed for amylase, lipase and chymotrypsin activities; enzyme outputs were calculated by standard marker perfusion techniques. Plasma levels of pancreatic polypeptide (PP) and motilin were also determined (RIA) at 15-min intervals.

RESULTS

Output of amylase, lipase and chymotrypsin occurred in parallel. All phase III motility fronts were accompanied by a pancreatic secretory peak. However, in 12 subjects at least one secretory peak was observed without the concomitant occurrence of phase III. A total of 16 out of 51 secretory peaks identified across all subjects were independent (31%). These phase III-independent peaks of pancreatic secretion occurred in subjects with a longer MMC cycle (160 +/- 19 min vs 102 +/- 13 min, P < 0.05). Phase III-associated and -independent peaks had a similar magnitude (amylase output: 21.6 +/- 3.9 kUh-1 vs 21.1 +/- 2.8 kUh-1, respectively). Irrespective of MMC phases, antral but not duodenal motor activity was closely correlated with fluctuations of pancreatic secretion (P < 0.05). Cycling of PP and motilin were also closely coordinated with pancreatic enzymes, with a particularly tight link between endocrine and exocrine secretion from the pancreas.

CONCLUSIONS

Peaks of pancreatic secretion invariably occur when a phase III motor activity occurs, but additional secretory peaks occur without a concomitant phase III. Interdigestive phasic pancreatic secretion is tightly coordinated with PP and motilin release as well as with antral motor activity. An intrinsic rhythm of the pancreas distinct from other cyclic activity may be present in healthy humans, expressed as peaks of pancreatic secretion independent of a motor phase III.

Increased risk for Helicobacter pylori recurrence by continuous acid suppression: a randomized controlled study

BACKGROUND AND AIMS

Acid hyposecretion may enhance Helicobacter pylori colonization. We tested the hypothesis that maintenance therapy with ranitidine after cure of Helicobacter pylori infection increases the risk of recurrence of infection.

PATIENTS AND METHODS

Sixty-six patients with duodenal ulcer and cured Helicobacter pylori infection were randomly assigned to 12 months maintenance treatment with ranitidine 150 mg daily (group A) or no treatment (group B). Follow-up consisted of clinical and endoscopic controls with biopsies for histology and rapid urease test every 4 months.

RESULTS

Six patients, 3 in each group, were lost to follow up. Helicobacter pylori recurrence occurred in 9 patients in group A and in 2 patients in group B (30% versus 7%; p < 0.05). Duodenal ulcer recurred in one patient in group A and in 2 in group B, all three patients were reinfected with Helicobacter pylori. A corpus-predominant gastritis was observed in all reinfected patients in group A but in none in group B.

CONCLUSIONS

Long-term inhibition of gastric acid secretion after eradication of Helicobacter pylori increases the risk of recurrence of infection. Our data imply that gastric acid not only influences the pattern of Helicobacter pylori localization in gastric mucosa, but also plays a key role in preventing recurrence of infection with Helicobacter pylori.

Effect of oral pancreatic enzyme administration on digestive function in healthy subjects: comparison between two enzyme preparations

BACKGROUND

Intraduodenal proteases exert a negative feedback on pancreatic secretion.

AIM

To investigate the effect of two pancreatic enzyme preparations (enteric-coated tablets, and capsules with enteric-coated microtablets) on postprandial pancreatic and bile acid secretion, gastroduodenal motility and release of gastrin and pancreatic polypeptide in healthy humans.

METHODS

Twenty healthy males were studied on two different days one week apart. After an overnight fast a nine-lumen motility tube was positioned with the distal tip at the Treitz angle. On each study day, 30 min after an interdigestive migrating motor complex-phase III, a semi-liquid test meal was given either alone (n = 20) or with enzymes (3 tablets (n = 10) or 2 capsules with microtablets (n = 10); 40,000 U lipase and 2000 proteases) in a randomized order, and the study continued over 2 h. Motility was continuously recorded with four ports in the antrum and three in the duodenum, using a low-compliance pneumohydraulic perfusion system. Secretion of human-specific pancreatic elastase and bile acids was measured by a standard duodenal intubation perfusion technique. Plasma concentrations of gastrin and pancreatic polypeptide were measured by specific radioimmunoassays.

RESULTS

Postprandial pancreatic secretion was significantly reduced by administration of microtablets (median 82 mg/2 h vs. 70 mg/2 h, P < 0.02) but not by tablets (median 59 mg/2 h vs. 58 mg/2 h. N.S.). No changes were observed in bile acid secretion, antroduodenal motility or release of gastrin and pancreatic polypeptide.

CONCLUSIONS

Oral administration of pancreatic enzymes at normal therapeutic doses significantly inhibits postprandial pancreatic secretion in healthy humans, when capsules with enteric-coated microtablets are given. Exogenous pancreatic enzymes have no significant effect on bile acid secretion, gastroduodenal motility and hormone release.

A citric acid solution is an optimal test drink in the 13C-urea breath test for the diagnosis of Helicobacter pylori infection

BACKGROUND

The 13C-urea breath test (13C-UBT) is a simple, non-invasive and reliable test for the diagnosis of Helicobacter pylori infection. The duration of the test, the timing of breath sampling, and the accuracy of the method vary according to the test meal used.

AIM

To identify the optimal test meal or drink for rapid and accurate performance of the 13C-UBT for the detection of H pylori infection.

PATIENTS

Eighty patients with dyspeptic symptoms were included. Of these, 48 patients had a positive H pylori status and 32 a negative one according to the results of the rapid urease test, histological examination, and culture.

METHODS

A 13C-UBT was performed after an overnight fast, on three consecutive days. On each study day a different test meal or drink was given (0.1 N citric acid solution, a standard semiliquid meal, or a semiliquid fatty meal) 10 minutes before giving 75 mg 13C-urea. Breath samples were collected at 0, 15, 30, 45, and 60 minutes, and analysed by isotype ratio mass spectrometry. Results were expressed as delta (delta) and considered as positive for H pylori if the highest delta (peak) was greater than 4.0.

RESULTS

The delta peak obtained with the citric acid drink in H pylori positive subjects (24.1 (SEM 1.5)) was significantly higher than that obtained with any of the semiliquid meals (13.3 (SEM 1.1) and 17.1 (SEM 1.0) respectively, p < 0.001). Furthermore, this delta peak was obtained earlier with the citric acid drink (30 (SEM 2) minutes) than with the other two meals tests (53 (SEM 2) min and 45 (SEM 2) min, p < 0.001). The sensitivity of the 13C-UBT for the diagnosis of H pylori infection was 96-100% with all three test meals. This high sensitivity was, however, obtained from 15 minutes by giving citric acid as the test drink, from 45 minutes by giving a semiliquid fatty meal, and at 60 minutes by giving the semiliquid standard meal. The specificity was 100% for all test meals. Citric acid is inexpensive and palatable to patients.

CONCLUSIONS

The 13C-UBT procedure with citric acid as the test drink is superior to the previously proposed semiliquid test meals in terms of 13CO2 recovery, time requirement, and cost. In routine clinical sampling, collection at times 0 and 30 minutes seems to be optimal and gives a high diagnostic accuracy.

Effect of omeprazole on Helicobacter pylori urease activity in vivo

BACKGROUND

Detection of Helicobacter pylori infection in clinical routine is based either on the direct visualization of the bacterium in gastric biopsies by histology or microbiology or on the demonstration of urease activity in gastric biopsies and by the labelled-urea breath test (UBT). Omeprazole has a strong inhibitory effect on H. pylori urease activity in vitro, but its effect in vivo and thus its influence on urease-based diagnostic procedures has not been investigated systematically.

AIM

To investigate whether omeprazole is able to inhibit H. pylori urease activity in vivo and, if so, at which doses.

PATIENTS

Eighteen patients with H. pylori associated chronic gastritis were studied.

METHODS

H pylori diagnosis was based on histology, rapid urease test and culture from antral biopsies. Following a positive H. pylori diagnosis patients received omeprazole 20mg (n = 6), 40mg (n = 6) and 80mg (n = 6) once daily for 5 days and 13C-UBT was performed on day 1, 3 and 5, 30min after each omeprazole administration. The 13C-UBT was performed with 200ml 0.1 N citric acid as test drink and 75mg 13C-urea. Breath samples were collected before and 30 min after 13C-urea administration.

RESULTS

A significant inhibition of urease activity was observed only under high dose omeprazole administration (80 mg/day), and the 13C-UBT turned negative in three (50%) of these patients after 5 days therapy.

CONCLUSION

Short-term omeprazole administration reduces H. pylori urease activity only at doses as high as 80 mg/day. A direct inhibition of enzyme activity as well as a reduction in the number of viable H. pylori bacteria may be responsible for this omeprazole-mediated reduction in urease activity. Urease-based diagnostic procedures for H. pylori are not suitable for patients under omeprazole therapy depending on the dose and duration of therapy.

Fecal elastase test: evaluation of a new noninvasive pancreatic function test

OBJECTIVES

Pancreatic elastase is highly stable along the intestinal tract. A new ELISA is commercially available to measure human specific elastase-1 concentration in stool. We evaluated the behavior of this fecal elastase test (FET) compared with other indirect pancreatic function tests in patients with chronic pancreatitis (CP).

METHODS

A total of 69 patients were included in the study, 20 of whom were diagnosed with CP according to the findings on ERP and CT; 13 patients had other pancreatic diseases, and the remaining 36 patients had gastrointestinal or hepatic disorders. All patients' elastase-1 concentrations and chymotrypsin activities [fecal chymotrypsin test (FCT)] were measured, and the serum pancreolauryl test (PLT) was performed.

RESULTS

Similar to PLT, fecal elastase concentration was significantly decreased in patients with moderate and severe CP (assessed by ERP) compared with patients with extrapancreatic disorders. However, and contrarily to PLT, FET was not affected by gastric resection, malabsorption due to intestinal disease, or marked alteration of the gastric motility. The sensitivity of FET was 100% for moderate to severe CP but 0% for mild CP; the specificity was 83%. Compared with other indirect pancreatic function tests, FET appears to be as sensitive as PLT and as specific as FCT, and it is clearly more specific than PLT and more sensitive than FCT. Unlike FCT, FET was not affected by oral enzyme supplementation.

CONCLUSION

FET is a simple and accurate functional test for CP, and it is hardly influenced by extrapancreatic disorders or therapy with exogenous enzymes.

Hyperlipidemia in acute pancreatitis. Cause or epiphenomenon?

Whether hyperlipidemia is a pre-existing metabolic disorder or a consequence of acute pancreatitis is still debated. Mild to moderate elevation of serum triglyceride levels are likely to be an epiphenomenon of the pancreatic disease. A marked hyperchylomicronemia and hypertrygliceridemia would be needed to trigger acute pancreatitis; a relevant defect in the lipid catabolism and clearance should therefore pre-exist. The aim of the present study was to investigate whether patients with acute pancreatitis and marked hyperlipidemia have an impaired clearance capacity of exogenous lipids, which would define the hyperlipidemia as a preexistent abnormality and therefore a potential cause of the pancreatic disease. With this aim, the kinetics of the removal of exogenous triglycerides from the circulation have been analyzed. Twenty patients with acute pancreatitis have been studied. Ten of them suffered from an episode of acute pancreatitis with marked hyperlipidemia (serum triglyceride levels > 20 mmol/L). Four to six months after recovery from the pancreatitis, a two-stage infusion of Intralipid 20% was carried out and the fractional removal rate (K2) and the maximal clearance capacity (K1) of exogenous triglycerides were calculated. At low infusion rates a first order kinetics for removal was observed, whereas at high infusion rates a zero order kinetics was operating. All patients with a previous attack of normolipidemic acute pancreatitis had normal K2 and K1 values. Five patients with previous hyperlipidemic acute pancreatitis had an abnormally low clearance capacity of exogenous triglycerides, whereas the remaining five had normal removal values. The present study provides new information in the association between hyperlipidemia and acute pancreatitis by showing that even a marked elevation of serum lipid levels should not be invariably considered as the etiological factor of the pancreatic disease, even if other potential causes are not evident.

Treatment of pain in chronic pancreatitis by inhibition of pancreatic secretion with octreotide

It has been suggested that pancreatic ductal hypertension, secondary to pancreatic outflow obstruction, is a cause of pain in chronic pancreatitis. This study investigated the effect of inhibiting pancreatic secretion with octreotide in chronic pancreatitis pain. Ten patients with chronic alcoholic pancreatitis and severe daily pain were included in an intraindividual double blind crossover study. All patients received octreotide (3 x 100 micrograms/day subcutaneously) and placebo (3 x 0.9% saline solution subcutaneously) for three days at random. Between both treatment phases a two day washout period was interposed. Intensity of pain (visual analogue scale) and analgesic consumption were carefully registered. Pancreatic secretion was monitored daily by measuring faecal chymotrypsin concentration. It was found that during the administration of octreotide, pancreatic secretion was strongly inhibited (faecal chymotrypsin mean (SD) 1.7 (0.6) U/g) with respect to placebo (9.6 (4.2) U/g) and washout (7.6 (3.1) U/g) periods (p < 0.001). Pain score (29.6 (4.5) v 28.7 (5.8)) and consumption of analgesics were no different during the octreotide and placebo periods. It is concluded that short term inhibition of pancreatic secretion does not result in pain relief in patients with chronic pancreatitis. This finding is in contrast with the hypothesis that outflow obstruction of pancreatic secretion with consequent ductal hypertension is an important cause of severe persistent pain in chronic pancreatitis.

Inflammatory response in the initial phase of acute pancreatitis: relationship to the onset and severity of the disease

Pathophysiological theories on acute pancreatitis and its complications have been always based on the harmful role played by the activated pancreatic digestive enzymes at local and systemic levels. However, acute pancreatitis is an inflammatory disease in which a complex systemic response is produced, which involves the interaction of cells (neutrophils, monocytes/macrophages, platelets, lymphocytes, endothelial cells and fibroblasts) and different proteolytic systems (coagulation, fibrinolysis, kallikrein and complement systems). The more or less severe evolution of the disease may depend on the intensity of this inflammatory response, according to the potential capacity of its mediators to cause significant damage at local and systemic levels. The initial mechanism of this response may be the release of oxygen free radicals by the damaged pancreatic cells, which are able to activate the cascade of digestive pancreatic enzymes and initiate chemotaxis and activation of inflammatory cells. Based on the actual knowledges, the present article aims to analyze the role of the inflammatory response on the severity of acute pancreatitis.

Exocrine pancreatic function in the early phase of human acute pancreatitis

BACKGROUND

Little is known about exocrine pancreatic function during human acute pancreatitis. We aimed to evaluate interdigestive exocrine pancreatic secretion and pancreatic polypeptide (PP) release during the early phase of acute pancreatitis in humans.

METHODS

Eight patients with acute pancreatitis (six biliary, one alcoholic, and one idiopathic acute pancreatitis) were studied within 72 h from the onset of symptoms. Four patients had necrotizing and four had edematous acute pancreatitis. Normal values were obtained from 26 normal subjects matched by sex and age. Interdigestive pancreatic secretion was studied by a duodenal intubation perfusion technique. Enzyme output was calculated for consecutive 15-min periods over 3-4 h and expressed as units per hour within a secretion cycle and units per hour around a secretion peak. Plasma PP concentrations were measured by radioimmunoassay in 15-min intervals.

RESULTS

All variables studied were similar in patients with acute pancreatitis and in controls. PP release in acute pancreatitis was maintained in a normal cyclical pattern closely related to the secretory cycles.

CONCLUSIONS

Interdigestive exocrine pancreatic secretion in the early phase of mild to moderate acute pancreatitis in humans remains within the normal range. This finding provides a rational basis for early therapeutic inhibition of pancreatic secretion in human acute pancreatitis.

Effect of pancreatic ductal and parenchymal changes on exocrine function in chronic pancreatitis

The effect of pancreatic ductal and parenchymal changes on exocrine pancreatic function was analyzed prospectively in 75 patients with chronic pancreatitis (CP). Endoscopic retrograde pancreatography (ERP), computed tomography (CT), and serum pancreolauryl test (PLT) were performed to evaluate the degree of ductal, parenchymal, and functional changes, respectively. Results were evaluated by stepwise multivariate logistic regression and are expressed as the odds ratio (OR). A strong association was found between the degree of ductal changes in ERP and the degree of exocrine functional impairment (OR = 5.8). However, the association between the degree of parenchymal changes in CT and the degree of pancreatic dysfunction was weaker and was clearly confounded by the degree of ductal changes. On the basis of these findings, we suggest that the development of exocrine pancreatic functional impairment in patients with CP depends primarily on the degree of ductal changes, while parenchymal abnormalities play a less important role.

Postprandial release of cholecystokinin and pancreatic polypeptide in health and in gallstone disease: relationships with gallbladder contraction

OBJECTIVES

The present study investigated endogenous postprandial release of cholecystokinin (CCK) and pancreatic polypeptide (PP) in relation to gallbladder dynamics in healthy subjects and patients with gallstones.

METHODS

Gallbladder volume (by ultrasonography) and plasma concentrations of CCK and PP (by radioimmunoassay) were evaluated in 18 patients with gallstones and 14 healthy controls before and after administration of a semi-liquid test meal (250 ml, 1450 kJ). Gallbladder contractility was previously assessed on a separate day by intravenous infusion of ceruletide (2.5 ng/kg/min).

RESULTS

Basal gallbladder volume was not different in patients (32 +/- 5.9 cm3) and controls (26 +/- 2.7 cm3). Postprandial gallbladder contractility was impaired in gallstone patients, who showed a reduced integrated response (-3718 +/- 349 vs. -5251 +/- 376 cm3/2 h, p < 0.01) and a delayed time to maximal gallbladder contraction (67 +/- 7.4 min vs. 37 +/- 2.4 min, p < 0.002). Maximal gallbladder contraction after ceruletide infusion was also reduced (44.1 +/- 5.0% vs. 72.5 +/- 3.2%, p < 0.001), but not delayed (15.8 +/- 2.4 vs. 15.7 +/- 1.4 min) in gallstone patients. Basal CCK and PP plasma levels were similar in both groups. Postprandial CCK release was impaired in gallstone patients, predominantly due to a decreased response over the first 30 min (3.8 +/- 1.8 vs. 20.0 +/- 4.9 pmol/L/30 min, p < 0.005). Postprandial PP release was not different between groups. A direct linear correlation between postprandial release of CCK and PP was found in healthy controls but not in patients with gallstones. Postprandial gallbladder volume at any moment was inversely correlated with CCK plasma levels in healthy subjects, but not in gallstone patients. No correlation between postprandial PP response and gallbladder dynamics was observed.

CONCLUSIONS

Based on a multivariate logistic approach, a reduced and delayed postprandial gallbladder contractility and an impaired CCK release in the early postprandial phase are significantly associated with gallstone disease. Our data provide further evidence for the predominant role of endogenous postprandial CCK release in gallbladder contraction. A role for PP in modulating postprandial gallbladder dynamics is not supported.

Chronic pancreatitis: management of pain

Pain is the main symptom in chronic pancreatitis (CP). Since frequency, duration, severity and cause of pain in CP differ in patients, pain management becomes a challenge for physicians, which often requires a multidisciplinary approach. The first step is the exclusion of any anatomic abnormality (e.g. pseudocysts, compression of adjacent visceral structures) that could be the origin of pain. Medical measures such as abstinence from alcohol, use of analgesics, and suppression of exocrine pancreatic secretion may be useful, mainly in patients with early- to moderate-stage CP. Endoscopic interventions may alleviate pain in some selected cases. When nonoperative measures fail to alleviate pain and pain interferes significantly with the quality of life, surgery should be considered. Celiac plexus block and epidural anesthesia are procedures to be used only in selected cases.

Management of severe acute pancreatitis

Currently, there is no specific therapy for acute pancreatitis. The management of the disease is supportive in approximately 80% of patients who suffer mild to moderate attacks. The remaining 20% of patients develop one or more major complications and require intensive care. Classification of acute pancreatitis according to severity is, therefore, necessary for proper management. Severe acute pancreatitis is detected early by the determination of circulating levels of polymorphonuclear elastase (PMN-E) and/or C-reactive protein (CRP). Patients with low levels of both PMN-E and CRP who have no major local or systemic complication of the disease can be classified as having mild acute pancreatitis. These patients require only supportive therapy and basic monitoring of vital functions. Patients with high levels of PMN-E and/or CRP and disease-related complications should be classified as severe. These patients should be managed in an intensive care unit for close monitoring of cardiovascular, respiratory, renal, metabolic, and hematological functions, and for early treatment of complications. Any organic dysfunction needs to be specifically treated. Development of extrapancreatic organ failure is closely related to the extent of pancreatic necrosis. Therefore, contrast-enhanced computed tomography (CT) should be performed in every patient classified as having severe acute pancreatitis. If sepsis develops, fine-needle ultrasound or CT-guided aspiration of necrotic tissue for bacteriological examination should be performed. Infected necrosis and persistent systemic failure under maximal intensive treatment require surgical treatment by necrosectomy and continuous lavage of the lesser sac. Late local complications of acute pancreatitis (i.e., abscesses and persistent pseudocyst) must be drained percutaneously or, more often, surgically.

Assessment of the fibrogenetic activity in chronic pancreatitis. The role of circulating levels of extracellular matrix components

Determination of circulating levels of extracellular matrix components has been proposed as a reliable method to assess the activity of fibrogenetic processes. Therefore, we aimed to analyze circulating levels of laminin, fibronectin, and procollagen III peptide (PIIIP) in patients with chronic pancreatitis (CP) and to correlate them with the morphological and functional stage, and duration of the disease. Thirty patients with CP and 18 healthy controls were studied. Serum PIIIP concentrations (RIA), but not fibronectin (RID) and laminin (RIA), were abnormally high in 8 patients with CP. No correlation was found between circulating levels of extracellular matrix components and both functional and morphological stage and duration of CP. Nevertheless, patients with elevated serum PIIIP levels tend to have a more advanced CP (morphological and functional changes) than those with normal levels after a similar duration of the disease. We hypothesize that whereas functional and morphological findings reflect the cumulative effect of chronic inflammation on the pancreas, serum PIIIP concentrations would reflect the activity of the fibrogenetic process within the gland at the time of sampling. The results shown in the present study may be considered a starting point for longitudinal studies that examine the relationship between serum PIIIP or other markers for fibrogenetic activity and evolution of CP.

Evaluation of the clinical usefulness of APACHE II and SAPS systems in the initial prognostic classification of acute pancreatitis: a multicenter study

The clinical usefulness of the APACHE II and SAPS systems in the early prognostic classification of patients with acute pancreatitis has been evaluated in a prospective multicenter study. We aimed to identify early those patients with acute pancreatitis who should be monitored closely to expedite the detection and treatment of complications. One hundred eighty-two patients with acute pancreatitis were included; 28 were classified as severe, having developed at least one major complication of the disease. The scores obtained through the APACHE II and SAPS systems in these severe cases were significantly higher than the scores in the mild cases of acute pancreatitis (p < 0.001). The sensitivity of these systems in the prognostic classification of acute pancreatitis was 70.4% for APACHE II and 66.7% for SAPS, and the specificity was 79.1% for both. When applying APACHE II and SAPS systems in the early phase of acute pancreatitis, the possibility of misdiagnosing the severity exists, thus limiting the application of these systems in the initial assessment of prognostic classification. In conclusion, APACHE II and SAPS systems are of limited clinical utility in the early prognostic evaluation of acute pancreatitis because of their low positive predictive value.

Clinical utility of the serum pancreolauryl test in diagnosis and staging of chronic pancreatitis

Indirect pancreatic function tests are frequently used in the clinical routine as complementary tools for the diagnosis of chronic pancreatitis (CP) because of their noninvasiveness and simplicity. We analyzed the clinical efficacy and routine application of a modified serum pancreolauryl test (PLT) in the diagnosis and staging of CP. We studied a total of 90 patients with CP diagnosed by endoscopic retrograde pancreatography and 54 patients with extrapancreatic gastrointestinal disorders as controls. Sensitivity and specificity of the serum PLT in the diagnosis of CP were 82% and 91%, respectively, using a value of 4.5 micrograms/ml as cutoff. In the diagnosis of patients with mild to moderate morphological changes of CP, the sensitivity of the serum PLT (52%) was improved by the concomitant analysis of serum pancreatic amylase in a logistic model (70%). Serum PLT closely correlated with the degree of pancreatic ductal abnormalities (p < 0.001), and showed a sensitivity of 81% and specificity of 89% in the staging of CP (mild-moderate vs. marked CP; cutoff 2.5 micrograms/ml). We conclude that the modified serum PLT is a reliable test which should be considered as a first-line option for the diagnosis and follow-up of patients with CP.

Monitoring of serum proteinase--antiproteinase balance and systemic inflammatory response in prognostic evaluation of acute pancreatitis. Results of a prospective multicenter study

With the aim of studying the clinical usefulness and applicability of circulating levels of protease inhibitors, complement factors, acute phase reactants, and leukocytic enzymes in the prognostic evaluation of acute pancreatitis (AP), the present prospective multicenter study has been carried out. A total of 182 patients with AP have been included, to whom an exhaustive evolutive protocol has been applied from the time of their hospital admission (2-12 hr from the onset of the disease) until the 15th day of evolution in order to clearly define them. The severe episodes exhibit a greater consumption of alpha 2-macroglobulin, and C3 and C4 complement factors, as well as a greater increase of alpha 1-protease inhibitor, C-reactive protein and polymorphonuclear elastase than mild events, with regards to the underlying pathophysiological condition. The determination of the plasma levels of leukocytic elastase in the first hours of evolution allows a prediction of the severity of the acute pancreatitis event with a high reliability (predictive values that become higher than 90%). The clinical value of the remaining parameters analyzed, in this aspect, is less, being applicable to the monitoring of the disease.

Effect of exogenous pancreatic enzymes on gastrointestinal and pancreatic hormone release and gastrointestinal motility

In clinical practice, exogenous pancreatic enzymes are administered for the treatment of pancreatogenic steatorrhea or with the intention to relieve pain due to chronic pancreatitis. Moreover, a large number of patients take pancreatin (i.e., exogenous pancreatic enzymes) for functional dyspepsia. The effect of exogenous pancreatic enzymes on the enteropancreatic axis is a complex issue. Intraduodenal but not intrajejunal protease activity appears to exert a dose-dependent negative feedback on exocrine pancreatic secretion. Only enzymes with a proteolytic activity but not amylase and lipase exert a control on pancreatic secretion. The mechanism responsible for this feedback regulation is debated, but the cholinergic system seems to play a major role. Intraduodenal pancreatic enzymes (pancreatin) lead to an increased release of pancreatic polypeptide but do not affect the release of insulin and glucagon. In addition, pancreatic enzymes have an influence on the release of some gastrointestinal hormones (i.e., cholecystokinin, motilin, gastric inhibitory polypeptide). Neither exogenous nor endogenous pancreatic enzymes seem to play a major role in the regulation of interdigestive gastrointestinal motility. However, an adequate rate of postprandial pancreatic output is required to control gastric emptying. Current knowledge on the effect of exogenous pancreatic enzymes on the enteropancreatic axis, gut peptide release and gastrointestinal motility are updated in the present article.

Ratios of different serum pancreatic enzymes in the diagnosis and staging of chronic pancreatitis

The aim of this study was to define an optimum serum enzyme ratio for the diagnosis of chronic pancreatitis (CP) and for the evaluation of the stage of the disease. With this goal in mind, a simultaneous and interrelated analysis of different serum pancreatic enzymes was performed in 296 consecutive patients with clinically suspected CP. A total of 167 patients were finally diagnosed with CP and 129 with other digestive diseases (used as controls). Serum values of pancreatic amylase, lipase, immunoreactive trypsin, and their ratios were determined in every patient before final diagnosis was established. Stepwise logistic regression analysis was performed. As expected, abnormally low values of individual serum pancreatic enzymes in the diagnosis of CP were highly specific (92-98%) but very insensitive (20-32%). Their diagnostic usefulness was neither improved by calculation of their ratios nor by the use of multivariate logistic regression analysis. A low pancreatic amylase/lipase ratio correlated with advanced CP (p < 0.01), and had a high degree of accuracy (80.5%) in the evaluation of the stage of the disease (assessed by endoscopic retrograde pancreatography). In conclusion, while serum pancreatic enzymes have limited usefulness in the diagnosis of CP, the pancreatic amylase/lipase ratio could be a simple method for staging the disease.