Effectiveness and Safety of Eliglustat Treatment in Gaucher Disease: Real-life Unicentric Experience

PURPOSE

The therapy and management of Gaucher disease (GD) have radically changed with the use of substrate reduction therapy, of which eliglustat is the most widely known drug, allowing it to overcome the limits of enzyme replacement therapy (ERT). The rarity of GD and the limited use of eliglustat outside clinical trials require further study of its strengths and weaknesses.

METHODS

In this study, we evaluated the effectiveness and safety of eliglustat in a cohort of 12 patients with GD followed up in our center, reporting a reduction in both chitotriosidase (394.3 vs 181.1 nmol/h/mL, P = 0.027) and glucosylsphingosine values (45.1 vs 18.9 ng/mL, P <0.001) after at least 12 months of therapy compared with baseline, regardless of patient demographic characteristics and GD characteristics.

FINDINGS

There were no drug-related serious adverse effects and no drug-related cardiac events. Most adverse events were mild and transient, mainly dyspepsia and abdominal pain. Of interest, we reported an absence of statistical difference in terms of response regarding glucosylsphingosine reduction in relation to naive or prior exposure to ERT (P = 0.296), which was confirmed also when patients were placed in naive and treated groups for <5 vs >5 years (P = 0.667).

IMPLICATIONS

The use of eliglustat immediately after diagnosis may guarantee the best treatment for patients with milder phenotypes or with aggressive disease after an initial stabilization with ERT compared with ERT, which cannot adequately remove the disease burden despite the apparent response, thus potentially reducing future complications caused by substrate deposits.

Alcoholic pancreatitis: new pathogenetic insights

Though amply described, alcoholic pancreatitis continues to stir controversy. One of the most debated points is whether it is a chronic disease since onset or progresses to a chronic form after repeated episodes of acute pancreatitis. Histologic studies on patients with pancreatitis have clearly shown that it is chronic since onset and that if necrotic acute pancreatitis develops in an alcoholic, it occurs in a pancreas damaged by chronic lesions. While the possibility cannot be wholly excluded that alcohol-related acute pancreatitis may develop in the absence of chronic lesions, such an occurrence would be rare. In addition to alcoholism, genetic factors play a determinant role in the pathogenesis of the disease. Genetic studies have suggested that in hereditary pancreatitis mutation of the cationic trypsinogen gene and serine peptidase inhibitor, Kazal type 1 (SPINK1) genes mutations of the may have pathogenetic importance; however, studies on alcoholic pancreatitis have produced disappointing results so far.

Benign pancreatic hyperenzymemia

Benign pancreatic hyperenzymemia is a newly identified syndrome characterized by an abnormal increase in serum pancreatic enzymes in the absence of pancreatic disease. The hyperenzymemia can occur sporadically or in a familial form, and all of the pancreatic enzymes show elevations. Although the condition is persistent, the enzyme elevations fluctuate considerably, even temporarily returning to normal levels at times. In this review the main characteristics of this syndrome are described.

The quality of life in patients with chronic pancreatitis evaluated using the SF-12 questionnaire: a comparative study with the SF-36 questionnaire

BACKGROUND

In clinical practice there is the need to utilise a time saving questionnaire to assess the quality of life.

AIMS

To establish the validity of the SF-12 questionnaire in chronic pancreatitis patients and to identify the predictors capable of modifying the physical and mental summaries in these patients.

QUESTIONNAIRES

SF-12 and SF-36 questionnaires were used.

SUBJECTS

One hundred and forty-one outpatients with proven chronic pancreatitis. The data of 141 sex- and age-matched Italian subjects of two normative groups (61,434 Italian subjects for SF-12 and 2031 Italian subjects for SF-36) were used as controls.

RESULTS

Chronic pancreatitis patients had the SF-12 physical and mental component summaries significantly related to the SF-36 physical and mental component summaries (P<0.001). The presence of pancreatic pain and non-pancreatic surgery accounted for 41.3% in the formation of the PCS-36 score and 37.2% in that of the PCS-12 score, respectively. Gender, BMI and pancreatic pain accounted for 15.3% of the information in the formation of the MCS-36 and for 14.7% in that of the MCS-12; using these clinical variables, the loss of information in applying the SF-12 instead of the SF-36 was very low (4.1 and 0.6% for the PCS and the MCS, respectively).

CONCLUSIONS

The SF-12 is a good alternative to the SF-36 in assessing the quality of life in chronic pancreatitis.

Quality of life in patients with chronic pancreatitis

INTRODUCTION

Health-related quality of life is becoming a major issue in the evaluation of any therapeutic intervention in patients with chronic or hard to cure diseases.

AIMS

To assess the quality of life in patients with chronic pancreatitis, the majority of whom have had the disease for a long time, and to evaluate which factors linked to the disease are able to influence the quality of life.

SUBJECTS AND METHODS

A total of 190 consecutive patients (157 males, 33 females; mean age 58.6+/-12.7 years, range 18-92 years) with proven chronic pancreatitis were enrolled. The SF-36 questionnaire was used for assessing the health-related quality of life.

RESULTS

The z-scores of the eight domains of the patients with chronic pancreatitis were significantly negative indicating an overall impairment of the quality of life when compared to the Italian normative sample. Pancreatic pain was the unique clinical variable able to significantly impair all eight domains of the SF-36, while Wirsung dilation and diabetes were negatively related to some physical and mental domains. The body mass index was the unique variable positively related with some SF-36 domains.

CONCLUSIONS

Pain may be considered the most important factor affecting the quality of life of chronic pancreatitis patients; moreover, alimentary and metabolic factors deserve more attention in improving the quality of life of these subjects.

Pancreatic hyperenzymaemia and hypertransaminasaemia in healthy subjects. Report of three cases

Three healthy subjects, two from Italy and one from the United States, showing a chronic increase in serum pancreatic enzymes and transaminases are described. The enzyme elevations reached very high levels but were not constant; rather, they fluctuated and sometimes returned to normal. Furthermore, tests for non-hepatic diseases that can be accompanied by an increase in serum transaminases, such as coeliac disease, were normal. The intervals between the first finding of the pancreatic hyperenzymaemia and the hypertransaminasaemia and this study ranged from 2 to 6 years (mean 4.3 years), during which the three subjects remained healthy, with no clinical, laboratory or imaging evidence of disease. These data support the conclusion that these increases in enzymes are benign; however, monitoring of these three subjects is already underway. Awareness of this anomaly is important, both to relieve the distress of the persons involved, as well as to avoid the numerous, sometimes invasive, complex and expensive examinations that might otherwise be unnecessarily performed.

A meal stimulation test in the diagnosis of pancreatic endocrine tumors in multiple endocrine neoplasia type 1

The diagnostic value of the determination of the serum pancreatic polypeptide (PP) and gastrin concentrations after a standard meal for early diagnosis of patients with multiple endocrine neoplasia type 1 (MEN 1) is controversial. The aim of this study was to clarify this issue. Thirteen patients with MEN 1, seven healthy family members, and eight healthy controls were studied. Plasma PP and serum gastrin were measured before and after the ingestion of a standardized meal. The meal caused a statistically significant (p < 0.05) increase of both PP and gastrin in all three groups studied. Concerning PP, no statistically significant difference was observed between patients and controls. In family members, the values were significantly (p < 0.05) lower than in the other two groups. On the whole, no significant differences in gastrin levels were noted between patients and controls; in family members, the values were significantly (p < 0.05) lower than in patients. All patients who had abnormally high postprandial values of PP and gastrin also had abnormally high basal values of these two peptides. The determination of serum PP and gastrin levels after a meal stimulation test in patients with MEN 1 adds no information about the presence of pancreatic endocrine tumors over that provided by basal values of the two peptides.

Do early symptoms of pancreatic cancer exist that can allow an earlier diagnosis?

Diagnosis of pancreatic cancer is made late, and prognosis remains extremely poor. This study was carried out to investigate whether symptoms exist before pain or jaundice that could suggest pancreatic cancer and favor earlier diagnosis. The study involved 305 patients with confirmed pancreatic cancer and 305 controls. All subjects were interviewed personally at least twice about their clinical history; pancreatic cancer patients were asked about any disturbances before abdominal pain or jaundice. Of the 305 pancreatic cancer patients, 151 (49.5%) had some prior disturbances, 108 (35.4%) 6 months or less before pain or jaundice and 43 (14.1%) more than 6 months before. Among the latter, 14 (4.6% of all patients) had had anorexia and/or early satiety and/or asthenia (7-20 months before pain or jaundice), 11 (3.6%) had disgust for coffee and/or smoking and/or wine (7-20 months before), 14 (4.6%) had diabetes (7-24 months before), and four (1.3%) had acute pancreatitis (8-26 months before). Among the controls, the only reports of these symptoms were two (0.7%) cases of asthenia (4 and 6 years earlier), 22 (7.2%) cases of diabetes (of which only two [0.7%] were diagnosed 7-24 months before the interview), and one (0.33%) case of acute pancreatitis (10 years earlier). Apart from acute pancreatitis, all the other differences between patients and controls were statistically significant. In approximately 15% of patients, disturbances existed more than 6 months before pain or jaundice, which, although not specific, could raise suspicion of the possibility of pancreatic cancer. These disturbances could represent the one current opportunity for an earlier diagnosis in a significant minority of pancreatic cancer patients.

Diagnostic value of plasma chromogranin A in neuroendocrine tumours

AIM

The aim of this study was to assess the value of plasma chromogranin A (CgA), a protein produced by neuroendocrine cells, in the diagnosis of neuroendocrine tumours.

METHODS

Eighty subjects with neuroendocrine tumours were studied. Thirty-four had carcinoids, 21 nonfunctioning endocrine pancreatic tumours, 17 multiple endocrine neoplasia type 1 (MEN 1) (six of these also had gastrinomas), and eight had functioning pancreatic tumours (four gastrinomas, two glucagonomas, two somatostatinomas). Twenty-eight healthy subjects were studied as controls. A fasting plasma sample was obtained from each subject, and CgA plasma levels were measured by the ELISA method using a kit (Dako A/S, Denmark).

RESULTS

In control subjects, plasma CgA values were below 5 U/l. Among the patients, 20 of the 34 with carcinoid tumours, 12 of the 21 with nonfunctioning pancreatic tumours, nine of the 17 with MEN 1 (including the six with gastrinomas), and the four gastrinomas of the eight functioning pancreatic tumours, i.e. overall, 45 of the 80 patients (56.3%) had abnormally high CgA values (22-961 U/l). Most of the patients with elevated CgA values, except nine of the 10 with gastrinomas, had multiple liver metastasis.

CONCLUSIONS

The results show that the diagnostic value of plasma CgA in neuroendocrine tumours is relatively low; it may be of some interest only in patients with advanced disease and liver metastasis. Gastrinoma seems to be an exception, because in this tumour high CgA values are generally found even in the absence of liver metastasis.

Multivisceral eosinophilic fibrosis: a new clinical presentation

We describe a patient who was referred to us with the diagnosis of pancreatic cancer but who had eosinophilic fibrosis of the pancreas and other organs, including the sub-mandibular salivary glands, retro-orbital tissue, liver, kidneys, and surrounding the abdominal aorta. He had no pain or other symptoms. After treatment with methylprednisolone, all lesions disappeared and now he seems to be cured of this apparently immune-mediated disorder. To our knowledge, involvement of all these particular organs by eosinophilic fibrosis in the absence of symptoms has never before been described.

Treatment of gastroenteropancreatic neuroendocrine tumours with octreotide LAR

BACKGROUND

Octreotide long acting repeteable (LAR) is a new somatostatin analogue whose activity lasts 28 days.

AIM

To assess its therapeutic efficacy, tolerability, and safety in patients with gastroenteropancreatic neuroendocrine tumours.

METHODS

A total of 16 patients were studied; 10 patients with carcinoid tumours, three with non-functioning pancreatic tumours, two with Zollinger-Ellison syndrome associated with multiple endocrine neoplasia type 1, and one with glucagonoma were studied. Octreotide LAR was administered intramuscularly at a dose of 20 mg every 28 days for a mean of 10.7 months (range 6-15 months).

RESULTS

In carcinoid tumour patients, octreotide LAR normalized bowel movements in nine out of 10 cases, and flushing episodes disappeared in seven out of eight cases. Even in the remaining six patients the symptoms disappeared. In carcinoid tumour patients, urinary 5-hydroxyindoleacetic acid decreased significantly. In the two patients with Zollinger-Ellison syndrome/multiple endocrine neoplasma type 1 and in the patient with glucagonoma, serum gastrin and plasma glucagon, respectively, decreased considerably. Tumour size remained unchanged in 14 out of 16 patients, and increased in the remaining two. No side-effects were observed.

CONCLUSIONS

Octreotide LAR appears to have a good therapeutic efficacy, tolerability and safety in the treatment of neuroendocrine tumours. Its effects are similar to those of octreotide and lanreotide. However, because it only needs to be administered once every 28 days, it is preferable in clinical practice.

Behaviour of serum pancreatic enzymes in chronic pancreatitis

AIM

To establish whether serum pancreatic enzyme determination is useful in the identification of patients with chronic pancreatitis and in revealing the presence of exocrine pancreatic insufficiency

PATIENTS AND METHODS

A total of 50 patients with chronic pancreatitis were included in the investigation: 19 were studied during a painful attack of the disease and 31 were observed during clinical remission of the disease and underwent a secretin-caerulein test; 21 of the 31 patients had severe pancreatic insufficiency. Thirty patients with non-pancreatic digestive diseases were also studied. Serum amylase, pancreatic isoamylase, lipase, trypsinogen and elastase- were determined in all patients.

RESULTS

Serum levels of the 5 enzymes studied were significantly higher in patients with pancreatic pain than in those studied during a clinical remission of the disease, and in those with non-pancreatic digestive diseases. In patients with chronic pancreatitis studied during clinical remission of the disease serum levels of pancreatic isoamylase and trypsinogen were significantly lower than in those patients with non-pancreatic digestive diseases. Considering only low serum concentrations of the five enzymes studied in diagnosing chronic pancreatitis, trypsinogen showed a sensitivity of 28%, specificity of 100%, a predictive value of a positive test of 100% and a predictive value of a negative test of 96.4%. In the 21 patients with severe pancreatic insufficiency, abnormally low serum concentrations of trypsinogen were found in 12 patients (57%), of lipase and elastase-1 in 6 (29%), of pancreatic isoamylase in 5 (24%), and of amylase in 3 (14%).

CONCLUSIONS

Serum pancreatic enzymes can not be considered a useful tool to identify patients with pancreatic insufficiency. However, of the five enzymes studied, serum trypsinogen appears to be a useful marker in the diagnostic work-up of chronic pancreatitis.

Familial pancreatic hyperenzymemia

I recently described a new form of pancreatic hyperenzymemia in healthy subjects in the absence of any pancreatic disease. The aim of this study was to determine whether this pancreatic hyperenzymemia has a familial distribution. From January 1996 to January 1999, 25 subjects with chronic nonpathological pancreatic hyperenzymemia were seen, in 23 of whom it was possible to investigate family members. A total of 102 subjects was studied. In addition to clinical history, physical examination and routine blood analysis, serum amylase, pancreatic isoamylase, lipase, and amylasuria were determined. Abdominal ultrasonography was also performed. Seven of the 23 families studied were found to have more than one member with pancreatic hyperenzymemia. In all, 19 persons (eight female and 11 male) were found to have this trait (mean age, 32.7 years; range, 3-84). The increase in enzyme concentration over the upper normal limit was in the range of 1.3- to 5.2-fold for amylase, 1.4- to 8.6-fold for pancreatic isoamylase, and 1.6- to 18.0-fold for lipase. Amylasuria was also increased. Clinically, no subject had symptoms or signs of pancreatic or other disease. Abdominal ultrasonography was normal in all of them. The results of this study show that pancreatic hyperenzymemia in healthy subjects may present with a familial distribution. The underlying defect in this disorder is not known. Although it is a benign condition, awareness of it is important to avoid unnecessary concern, examinations, and expenditure.

Medical treatment of chronic pancreatitis

The medical treatment has an important role in patients with chronic pancreatitis. Pain is the most frequent symptom, at least in the initial phases of the disease. In about 60% of patients it can be successfully treated by medical therapy; in the remaining 40% it requires surgery. Malabsorption of fat and protein and diabetes usually appear in the advanced stages of the disease. The treatment of these complications is based on the administration of pancreatic extracts and insulin. There are several types of pancreatic extracts; the most useful are those with high lipase content and high lipase-protease ratio. Moreover, they should be protected against gastric acid and should have a gastric emptying simultaneously with chyme, with a rapid liberation of enzymes into the duodenum. The treatment of diabetes usually requires low-moderate doses of insulin. Diabetic ketoacidosis is rare, while microvascular changes have the same frequency as in type 1 diabetes.

Diabetes and the risk of pancreatic cancer

AIMS

Diabetes occurs more frequently in patients with pancreatic cancer than in the general population, and it has repeatedly been claimed that it is a risk factor for this tumor. However in most of the studies on this subject the duration of diabetes before the diagnosis of pancreatic cancer was not ascertained. In an attempt to clarify the cause of the association between these two pathologic conditions and to determine whether diabetes is a risk factor for pancreatic cancer we recently studied this association in a large number of patients with pancreatic cancer.

METHODS

A total of 720 patients with newly diagnosed pancreatic cancer (415 men and 305 women; mean age 62.6 years, range 22 to 79 years) and 720 controls matched for sex, age, social class, and geographic region, were enrolled in the study. All subjects were interviewed personally and in detail about their clinical history. The diagnosis of diabetes was based on criteria recommended by the American Diabetes Association.

RESULTS

One hundred sixty-four patients with pancreatic cancer (22.8%) and 60 controls (8.3%) had diabetes. In the majority of the patients with pancreatic cancer (56.1%), diabetes was diagnosed either concomitantly with the cancer (in 40.2%), or within two years before the diagnosis of cancer (in 15.9%). The association between the two conditions was significant (odds ratio, 3.04; 95% confidence interval, 2.21 to 4.17). However, when only patients with diabetes of three or more years' duration were considered, the association was no longer significant (odds ratio, 1.43; 95% confidence interval, 0.98 to 2.07). All the patients with pancreatic cancer whose diabetes had been diagnosed before the cancer had non-insulin-dependent diabetes; all but one of the control patients with diabetes had the non-insulin-dependent form of the disease.

CONCLUSIONS

Diabetes in patients with pancreatic cancer is frequently of recent onset and is presumably caused by the tumor. Diabetes is not a risk factor for pancreatic cancer.

Risk of pancreatic and periampullary cancer following cholecystectomy

AIMS

Cholecystectomy has been reported by several investigators to increase the risk of pancreatic cancer. The trophic effect on the gland by increased release of cholecystokinin following cholecystectomy and perturbation of the neurohormonal pancreatic regulation, have been suggested as possible contributing factors. However, while several investigators found that this surgical procedure increases the risk, others have not. In an attempt to clarify whether or not patients who have undergone cholecystectomy are at increased risk for developing pancreatic cancer, we evaluated the frequency with which cholelithiasis and this surgical procedure were present in a large number of patients with pancreatic cancer.

METHODS

A total of 720 patients with newly diagnosed pancreatic cancer (415 men and 305 women; mean age 62.6 years, range 22 to 79 years) and 720 controls matched for sex, age, social class, and geographic region, were enrolled in the study. All subjects were interviewed personally and in detail about their clinical history.

RESULTS

Cholelithiasis was present in 126 patients with pancreatic cancer (17.5%) and in 95 controls (13.2%), constituting a statistically significant association (odds ratio, 1.39; 95% confidence interval, 1.04 to 1.86). However, considering only the patients and controls in whom the diagnosis of cholelithiasis was made for more than one year before cancer diagnosis or interview, the association was no longer significant (odds ratio, 1.04; 95% confidence interval, 0.75 to 1.44). Cholecystectomy had been performed in 93 patients with pancreatic cancer (12.9%) and in 71 controls (9.9%). When all subjects were considered, the odds ratio was mildly, although not significantly, increased (odds ratio, 1.35; 95% confidence interval, 0.97 to 1.87). When only subjects who underwent cholecystectomy one year or more before the cancer diagnosis or interview were considered, the odds ratio fell to unity (odds ratio, 1.00; 95% confidence interval, 0.70 to 1.43).

CONCLUSION

This study, one of the largest on this topic, clearly shows that there is no evidence for an association between cholelithiasis, cholecystectomy, and pancreatic cancer.

Fecal elastase 1 determination in chronic pancreatitis

This study assessed the diagnostic accuracy of fecal elastase 1 in chronic pancreatitis. Fifty-three healthy subjects, 44 patients with chronic pancreatitis (22 severe, 13 moderate, and 9 mild), and 43 patients with nonpancreatic digestive disease were studied. Elastase 1 concentration was determined on a small sample of feces using a commercially available kit. Fecal chymotrypsin was also measured. With a cutoff level of 190 microg/g, all healthy controls except one (98.1%), and the majority of patients with nonpancreatic digestive diseases (40 of 43; 93.0%) had elastase values above this limit. Among the 44 patients with chronic pancreatitis, 34 (77.3%) had pathological values: all 22 (100%) with severe disease, 10 of 13 (76.9%) with moderate disease and 2 of 9 (22.2%) with mild disease. Chymotrypsin values were pathological in 25 of 44 (56.8%) patients with chronic pancreatitis: 17 of 22 (77.2%) with severe pancreatitis, 7 of 13 (53.8%) with moderate pancreatitis, and 1 of 9 (11.1%) with mild disease. The specificity was 95.8% for elastase 1 and 85.4% for chymotrypsin. The difference both in sensitivity and specificity of the two enzymes was statistically significant (P < 0.05). Fecal elastase 1 has a high sensitivity, superior to that of fecal chymotrypsin, in the diagnosis of chronic pancreatitis. For its simplicity and rapidity, it could represent the tubeless test of choice in chronic pancreatitis.

Slow-release lanreotide treatment in endocrine gastrointestinal tumors

OBJECTIVES

Lanreotide is a somatostatin analogue whose activity persists for 10-14 days. In this study, we treated a group of patients with gastrointestinal endocrine tumors with lanreotide to assess its therapeutic efficacy and tolerability.

METHODS

Eighteen patients, 12 male and six female, mean age 58 yr (range, 25-80 yr) were studied. Ten had carcinoid tumors, five had nonfunctioning endocrine tumors, two had glucagonomas, and the remaining one had a gastrinoma. All patients had somatostatin receptors, demonstrated by octreoscan scintigraphy. Lanreotide was administered intramuscularly at a dose of 30 mg every 10 days, for a mean of 12 months (range, 5-18 months). Fifteen of the 18 patients had been previously treated with octreotide.

RESULTS

In patients with carcinoid tumors, lanreotide markedly reduced daily bowel movements and flushing episodes. A reduction was also observed in urinary serotonin and urinary 5-hydroxyindoleacetic acid, although it was not statistically significant. A marked reduction in symptoms, and in plasma glucagon and serum gastrin levels, was also observed in patients with glucagonoma and gastrinoma. In the five patients with nonfunctioning endocrine tumors, as in all the other 13 patients, no significant effects were noted in the size of the tumor. The administration of lanreotide did not cause side effects, apart from transient abdominal pain and pain at the injection site in two patients. Only in the patient with gastrinoma was lanreotide suspended, because of the appearance of attacks of marked hypoglycemia. In the 15 patients previously treated with octreotide, no differences in the effects were noted with lanreotide.

CONCLUSIONS

Lanreotide has a satisfactory therapeutic efficacy and tolerability in the treatment of gastrointestinal endocrine tumors; its effects are similar to those of octreotide. However, unlike octreotide, it can be administered once every 10-14 days, instead of 2 or 3 times daily and for this reason, it is preferable in clinical practice.

Asymptomatic glucagonoma presenting with an isolated hepatic nodule

A 37-year-old male patient, without any particular symptoms apart from moderate right upper quadrant postprandial pain, was found to have a liver mass identified as a glucagon-producing tumor. Plasma glucagon levels were slightly increased, whereas those of other gut peptides were within the normal range. Despite an extensive pre- and intraoperative diagnostic work-up, a presumed primary glucagonoma remained undetected. This unusual presentation with the absence of any symptoms typical of glucagonoma, as well as the presence of histopathological features characteristic of both benign and malignant forms of glucagonoma, make this case very peculiar. A clinically silent, apparently unrelated adenocarcinoma of the left colon was also found. The concomitant presence of a glucagonoma and a carcinoma of the large intestine has not been previously reported, and its significance remains unclear.

Serum pancreatic enzymes in patients with coma due to head injury or acute stroke

Serum amylase and lipase were measured in 32 patients with cerebral ischemia, 19 with spontaneous cerebral hemorrhage, 15 with head injury and intracranial bleeding, and 22 with head injury without intracranial bleeding; 20 healthy subjects were also studied as controls. Serum pancreatic isoamylase concentrations were assayed in hyperamylasemic sera. The overall incidence of hyperamylasemia was 14% (12 of 88 patients: 4 with cerebral ischemia, 4 with spontaneous cerebral hemorrhage, 1 with head injury and intracranial bleeding, and 3 with head injury without intracranial bleeding). In 4 of the 12 patients the hyperamylasemia was of pancreatic origin: 1 patient with cerebral ischemia, 1 patient with spontaneous cerebral hemorrhage, 1 patient with head injury and intracranial bleeding, and 1 patient with head injury without intracranial bleeding. The incidence of hyperlipasemia was 7% (6 of the 88 patients: 1 patient with cerebral ischemia, 2 with spontaneous cerebral hemorrhage, and 3 with head injury without intracranial bleeding). We conclude that hyperamylasemia is more frequent than hyperlipasemia in patients with an altered state of consciousness due to head injury or stroke and is usually of non-pancreatic origin. This knowledge may save these patients from invasive and costly examinations.

Role of color Doppler ultrasonography in the preoperative staging of pancreatic cancer

We describe our experience with color Doppler ultrasonography (CDU) in the preoperative staging of pancreatic cancer and, particularly, in detecting the involvement of the portal-mesenteric trunk (PMT). Of the 54 patients studied, 43 (79.6%) underwent surgery and 11 (20.4%) did not because of evident infiltration of the PMT. Of the 43 patients operated on, the CDU study was normal in 8 cases (18.6%), abnormal in 33 (76.7%), and not possible in the remaining 2 cases (4.7%). Results of the CDU were confirmed intraoperatively in 39 cases (diagnostic accuracy, 95.1%). In only two cases (4.9%) did the CDU not show involvement of the PMT, which was, instead, demonstrated by intraoperative ultrasonography (false negatives). Of the 11 nonoperated patients, all showed morphological alterations at CDU, while only 7 showed hematic flow changes. The sensitivity of CDU was 94.2% and the specificity 100%. The positive predictive value was 100%; the negative predictive value, 75%. The results indicate that CDU may be the first imaging technique for preoperative assessment of PMT involvement in pancreatic cancer.

Plasma cholecystokinin and neurotensin after an ordinary meal in humans. A prolonged time study

BACKGROUND/AIM

Ingestion of a meal causes the release of cholecystokinin and neurotensin into the circulation, but little is known about the duration of this release.

METHODS

Six healthy volunteers were studied. Blood samples for cholecystokinin, neurotensin and gastrin assessment were drawn before and after consumption of a typical Italian lunch. Postprandial samples were obtained every hour for a total of 10 hours. All peptides were measured using previously validated radioimmunoassays.

RESULTS

Ingestion of the meal caused a prompt and significant increase in plasma levels of all three peptides. Cholecystokinin remained elevated for about 7 hours and then tended to return towards basal values, whereas the increase of neurotensin persisted for the entire period of the study (10 hours). Gastrin remained elevated for about 5 hours and then declined. The integrated CCK and gastrin responses during the initial postprandial hours were greater than those in the late hours, whereas the integrated neurotensin response during the initial hours was lower than that in the late hours.

CONCLUSIONS

The results indicate that, after an ordinary meal, cholecystokinin is released into the circulation for about 7 hours, much longer than previously reported (3-4 hours). The release of neurotensin begins soon after the meal and persists even longer, for at least 10 hours. Possible physiological implications of these findings are discussed.

Stimulation of gallbladder emptying by intravenous lipids

BACKGROUND

Few studies have dealt with the effect of i.v. administration of lipids on gallbladder emptying, and the results have been conflicting.

METHODS

Five healthy volunteers, three women and two men, aged 26 to 54 years, (mean, 29 years) were studied. Gallbladder emptying was assessed by means of real-time ultrasonography.

RESULTS

In all subjects, the infusion of a 10% fat emulsion (Intralipid; Kabivitrum, Stockholm) over 3 hours caused a reduction in gallbladder volume. This effect was statistically significant at about 80 minutes of lipid infusion and became progressively more marked as the infusion progressed, reaching a reduction of approximately 30% during the third hour of infusion. A significant relationship (p < .001) was found between the concentration of serum triglycerides and the degree of gallbladder volume decrease. In control studies, infusion of physiologic saline containing glycerol, the excipient of intralipid, caused no significant changes in gallbladder volume.

CONCLUSIONS

The results indicate that i.v. infusion of lipids is able to stimulate significantly contraction of human gallbladder.

Faecal elastase 1 in children with cystic fibrosis

Recently, a new ELISA kit for determination of elastase 1 in faeces has become commercially available. Studies in patients with chronic pancreatitis have indicated that it is a simple and sensitive test of exocrine pancreatic function. The aim of this study was to assess the clinical value of this new test in cystic fibrosis. A total of 72 children were studied: 27 who were healthy, 22 with cystic fibrosis and 23 with non-pancreatic disorders. Oral pancreatic extracts were not discontinued in the children with cystic fibrosis. A small sample of faeces was collected from each subject for elastase 1 concentration and chymotrypsin activity determination. In all of the healthy children and most of those with non-pancreatic disorders (20/23), elastase 1 concentrations were greater than 500 microg/g; in contrast, the vast majority (20/22) of children with cystic fibrosis had very low values (less than 20 microg/g). The differences between children with cystic fibrosis and the other two groups were highly significant (P < 0.001). With a cut-off level of 132 microg/g, the sensitivity and specificity of faecal elastase 1 for the determination of exocrine pancreatic insufficiency were 96% and 100%, respectively. The specificity of faecal chymotrypsin was 96%, but its sensitivity was not calculated since the children with cystic fibrosis continued to take pancreatic extracts during the study.

CONCLUSION

The determination of faecal elastase 1 concentration is a simple and reliable means of assessing exocrine pancreatic function in children with cystic fibrosis. Results are not influenced by non-pancreatic disorders or by enzyme supplementation.

Clinical value of pancreatitis-associated protein in acute pancreatitis

OBJECTIVES

Pancreatitis-associated protein (PAP) is a secretory protein that is overexpressed by the pancreas during acute pancreatitis. This study was carried out to assess the clinical value of PAP in acute pancreatitis, particularly its ability to indicate the severity of the disease.

METHODS

Twenty-one healthy subjects, 58 patients with acute pancreatitis, and 20 patients with nonpancreatic acute abdomen were studied. In addition to serum PAP concentration, serum concentrations of amylase, lipase, and C-reactive protein (CRP) were measured at admission and, in patients with acute pancreatitis, during the following 5 days.

RESULTS

On admission, serum PAP concentrations were abnormally high in 46 of the 58 patients with acute pancreatitis (79%); serum amylase, in 57 patients (98%); serum lipase, in all patients (100%); and serum CRP, in 40 patients (69%). During the subsequent days of the study, PAP and CRP tended to increase, whereas amylase and lipase decreased. No significant differences in PAP or amylase and lipase concentrations were found between patients with mild pancreatitis and those with severe pancreatitis during the entire study period, whereas from the third day to the sixth day, CRP concentrations were significantly higher in patients with severe pancreatitis than in those with mild pancreatitis. Among the 20 patients with nonpancreatic acute abdomen, PAP concentrations were abnormally high in 10 (50%), whereas amylase concentrations were abnormally high in five (25%), and lipase concentrations were high in two (10%).

CONCLUSIONS

Our results indicate that the clinical value of PAP in acute pancreatitis is quite limited and, in particular, that PAP is not a useful marker for determining the severity of the disease.

Unusual association of macroamylasemia and hyperlipasemia: report of two cases

OBJECTIVE

To describe two cases of macroamylasemia associated with hyperlipasemia.

METHODS AND RESULTS

The patients were a young male soccer player who had sustained a kick in the groin during a match and a woman with a specific dyspeptic complaints. In both the macroamylasemia had been previously undetected; when admitted with the above complaints, serum pancreatic isoamylase levels, as determined by the inhibitor method, were markedly increased, as were serum lipase levels. In both cases these findings led to the erroneous diagnosis of pancreatitis and consequent multiple diagnostic and therapeutic procedures. The cause of the hyperlipasemia was not clear in either case, although the possibility that it was due to the presence of macrolipase cannot be excluded.

CONCLUSION

The possibility of macroamylasemia associated with hyperlipasemia should be kept in mind to avoid unnecessary diagnostic and therapeutic efforts.

Effects of ischemia on the human pancreas

BACKGROUND & AIMS

Patients undergoing cardiac surgery frequently have pancreatic damage; several factors, including tissue hypoperfusion, have been implicated. The aim of this study is to better understand the effects of decreased blood supply on human pancreas.

METHODS

Twenty-one consecutive patients undergoing surgery for thoracic or thoracoabdominal aortic aneurysm were studied. During surgery, the descending thoracic aorta was cross-clamped for a mean of 44 minutes (range, 15-85 minutes). Effects of the resultant pancreatic ischemia were assessed by examining the patients daily for evidence of acute pancreatitis for at least 20 days after surgery and by determining serum concentrations of amylase, pancreatic isoamylase, and lipase before clamping the aorta and at varying intervals after its release (1, 2, and 6 hours during the first day and once daily for the following 6 days).

RESULTS

One patient died of acute necrotizing pancreatitis. None of the others had symptoms of pancreatitis postoperatively, but all showed a significant increase in serum pancreatic enzyme concentrations soon after declamping; this peaked about 24 hours later and persisted for all 7 days of the study. A significant relationship was found between the increase in pancreatic enzyme concentrations and the aortic clamping time.

CONCLUSIONS

Acinar cell injury is a constant, rapidly appearing consequence of severe pancreatic ischemia, even that of brief duration; acinar cell injury is usually subclinical but may also present as severe acute pancreatitis.

Risk of pancreatic cancer associated with cholelithiasis, cholecystectomy, or gastrectomy

Current data regarding an association between cholelithiasis, cholecystectomy, or gastrectomy and pancreatic cancer are conflicting. We evaluated the frequency with which these factors were present in 720 patients with newly diagnosed pancreatic cancer and in 720 matched controls. All subjects were interviewed personally and in detail about their clinical history. Cholelithiasis was present in 126 patients with pancreatic cancer (17.5%) and in 95 controls (13.2%), constituting a statistically significant association (odds ratio, 1.39; 95% confidence interval, 1.04-1.86); however, considering only the patients and controls in whom the diagnosis of cholelithiasis was made more than one year before cancer diagnosis or interview, the association was no longer significant (odds ratio, 1.04; 95% confidence interval, 0.75-1.44). Cholecystectomy had been performed in 93 patients with pancreatic cancer (12.9%) and in 71 controls (9.9%). When all subjects were considered, the odds ratio was mildly, although not significantly, increased (odds ratio, 1.35; 95% confidence interval, 0.97-1.87); when only subjects who underwent cholecystectomy one year or more before the cancer diagnosis or interview were considered, the odds ratio fell to unity. Gastrectomy had been performed in 28 patients with pancreatic cancer (3.9%) and in 25 controls (3.5%); analysis revealed no significant association between these two factors (odds ratio, 1.14; 95% confidence interval, 0.64-2.05). In conclusion, our study, one of the largest on this topic, has found no evidence for an association between cholelithiasis, cholecystectomy, or gastrectomy and pancreatic cancer.

[The risk factors for pancreatic cancer]

This review summarises the current state of knowledge regarding the risk factors for pancreatic cancer. Of all the factors studied, only smoking is well established. Excessive dietary fat and protein may increase the risk, but this has not been proven conclusively. Fruits and vegetables, on the other hand, may offer a protective effect. The role of coffee remains controversial. There is no concrete evidence that alcohol, tea, occupational exposure, diabetes, gallstones, cholecystectomy or gastrectomy are significantly associated with this tumour. A possible predisposing role for chronic pancreatitis cannot be excluded.

Chronic nonpathological hyperamylasemia of pancreatic origin

BACKGROUND & AIMS

Pancreatic hyperamylasemia is usually an expression of pancreatic disease. This study describes pancreatic hyperamylasemia in the absence of pancreatic disease.

METHODS

Eighteen subjects with this form of hyperamylasemia were referred to our unit from January 1987 to June 1991. Amylase and pancreatic isoamylase as well as serum lipase and trypsin concentrations were determined, and ultrasonography and computed tomography were performed in all patients. After initial evaluation, they were seen annually for clinical assessment, ultrasonography, and serum enzyme determination until December 1995. At the final evaluation, all underwent a pancreatic function study.

RESULTS

In 14 of the 18 subjects, all enzyme levels assessed were abnormally elevated; in 3 subjects, all but the lipase level were abnormally elevated, and in the remaining subject, all but the trypsin level were abnormally elevated. The increase over the upper normal limit was in the range of 1.4-4.1-fold for amylase, 1.8-6-fold for pancreatic isoamylase, 1.5-7.7-fold for lipase, and 1.6-13.9-fold for trypsin. During follow-up, enzyme concentrations remained elevated, although wide fluctuations and occasional transient normalization were observed. No subjects had evidence of pancreatic disease either at initial evaluation or during follow-up.

CONCLUSIONS

This is the first detailed description of chronic nonpathological pancreatic hyperamylasemia as a distinct entity. The reasons for this enzyme alteration are unknown.

Pericardial effusion and left ventricular function in acute pancreatitis

OBJECTIVES

To establish the prevalence of pericardial effusion and to evaluate left ventricular function in patients with acute pancreatitis.

METHODS

Twenty-one consecutive acute pancreatitis patients were studied. In 15 patients, the pancreatitis was of biliary origin and was attributable to other causes in the remaining six; eight patients had severe pancreatitis and 13 a mild disease. Using M-mode and B-mode echocardiography, pericardial effusion and left ventricular function were evaluated in all of the patients within 48 h of pain onset. All patients underwent an electrocardiogram and a standard chest x-ray. In 12 patients, the same parameters were evaluated 1 month after clinical recovery. Twenty healthy subjects, comparable for sex and age, have been studied as controls.

RESULTS

Left ventricular function was similar in patients with acute pancreatitis and in healthy subjects; it was also similar both in patients with biliary and nonbiliary pancreatitis as well as in patients with severe pancreatitis and in those with mild disease. In the 12 patients in whom echocardiography was performed on hospital admission and one month after clinical recovery, no changes of left ventricular function were observed. Two patients with a mild form and one with a severe disease had pericardial effusion. One patient had negative T waves at electrocardiogram and an apical asynergy at echocardiography; these alterations disappeared after recovery. Chest x-ray revealed pleural effusion in seven patients with severe pancreatitis, whereas no alterations of cardiac silhouette were found. Acute abdominal fluid collections were also detected in seven of eight patients with severe pancreatitis, by contrast-enhanced computed tomography.

CONCLUSIONS

The presence of pericardial effusion or left ventricular asynergy may be observed occasionally at echocardiography in acute pancreatitis patients; these findings, in contrast to the presence of pleural and abdominal effusions, seem to be unrelated to the severity of the disease.

Increased prevalence of aortic calcification in chronic pancreatitis

OBJECTIVES

The seemingly frequent radiological observation of aortic calcification in patients with chronic pancreatitis seen in our clinic prompted us to assess the prevalence of this lesion in this disease.

METHODS

Fifty-seven consecutive patients with chronic pancreatitis (52 male, five female; mean age 44.2 yr, range 26-59 yr), and 66 healthy controls, matched for sex and age, were studied. Of the 66 controls, 40 were both smokers and drinkers, as were most of the patients. The presence of aortic calcification was determined by performing anteroposterior and lateral radiograms of the prelumbar region.

RESULTS

Radiological evidence of aortic calcification was found in 35 of the 57 patients with chronic pancreatitis (61.4%) and in 12 of the 40 smoker control (30.0%) (p < 0.005); none of the nonsmoker controls had aortic calcification. The increased frequency was more pronounced among the patients under 50 yr of age (40.0% vs. 0% and 70.4% vs. 35.3% in the 30-39 and 40-49 yr age groups, respectively). No significant differences in serum levels of cholesterol and triglycerides, blood pressure, alcohol, and smoking habits were observed between chronic pancreatitis patients with aortic calcification and those without, or between patients with aortic calcification and controls.

CONCLUSIONS

The results indicate that patients with chronic pancreatitis have a significantly higher prevalence of aortic calcification than controls. The reason for the increased prevalence of this advanced atherosclerotic lesion is nuclear.

Somatostatin analogues and exocrine pancreatic secretion

Subcutaneous injection of 50 micrograms octreotide before a meal can almost totally prevent the increase in exocrine pancreatic secretions caused by the meal. Octreotide inhibits plasma amino acid uptake by pancreatic acinar cells, and thus synthesis of pancreatic enzymes. This effect has clinical potential.

Diagnostic value of the amino acid consumption test in pancreatic diseases

The amino acid consumption test (AACT) has been proposed as a simple tubeless test of pancreatic function, but studies of its diagnostic accuracy have produced conflicting results. Eighty-three consecutive patients with clinical suspicion of pancreatic disease underwent pancreatic stimulation for 1 h with an intravenous infusion of cerulein (50 ng/kg/h); the total plasma amino acid concentration was measured at -15, 0, 30, 45, and 60 min of infusion. The maximal percentage decrease in plasma amino acid concentration during cerulein infusion was taken as an index of pancreatic function. In addition, patients had pancreatic function assessed with the pancreolauryl test (PLT). Of the 83 patients studied, 24 were found to have chronic pancreatitis and four pancreatic cancer; the remaining 55 had various nonpancreatic digestive disorders. Pancreatic function, as assessed by the PLT, was impaired in 22 of the 28 patients with pancreatic diseases, and it was normal in all but four patients with nonpancreatic disorders. Cerulein infusion caused a decrease in total plasma amino acid concentration that was generally more pronounced in patients with nonpancreatic diseases (maximal percentage decrease: median, 14%; range, 4-28%) than in those with pancreatic diseases (maximal percentage decrease: median, 9%; range, 0-21%) (p < 0.001). Using a cutoff of a 14% amino acid decrease, the sensitivity of the AACT was 89% and the specificity 53% (diagnostic accuracy, 65%); with a cutoff of 12%, the sensitivity was 75% and the specificity 69% (diagnostic accuracy, 71%). The sensitivity of the PLT was 79% and the specificity 93% (diagnostic accuracy, 88%). The results indicate that the sensitivity of the AACT is relatively high, but they show that the specificity is low, making the test unsuitable for clinical use, at least in its present form.

Is chronic pancreatitis a cause of dyspepsia?

Chronic pancreatitis is commonly included among the organic causes of dyspepsia, however the frequency and characteristics of this association are ill-defined. One-hundred-fifteen consecutive patients with chronic pancreatitis and 85 healthy subjects were interviewed regarding their clinical history, with particular attention to dyspeptic symptoms. Attacks of prolonged upper abdominal pain, recurring at unpredictable intervals and in most cases without identifiable triggering factors, were the most frequent clinical manifestation (108, 94%). During the attacks, many patients (66, 61%) complained of vomiting, which was generally mild and of brief duration. Between the attacks, very few patients (12, 10%) complained of dyspeptic disturbances, mainly postprandial epigastric fullness and abdominal bloating. These complaints were episodic, usually after abundant meals, in 8, and persistent in the remaining 4. Among these 12 patients, there were no significant differences in the frequency of dyspeptic symptoms in relation to the severity of exocrine pancreatic insufficiency. The frequency of dyspeptic complaints among patients (10%) was significantly lower (p < 0.01) than the frequency of dyspeptic symptoms among the controls (25%). The results of this study indicate that, other than recurrent attacks of abdominal pain, dyspeptic symptoms are uncommon in chronic pancreatitis, and that impairment of digestion of pancreatic origin is not a cause of dyspepsia.

Coffee and cancer of the pancreas: an Italian multicenter study

While cigarette smoking is a well-established risk factor for pancreatic cancer, the role of alcohol, coffee and tea consumption remains controversial. In view of this, and because of the limited information on possible environmental risk factors of pancreatic cancer in Italy, we carried out this study. Five hundred seventy patients with newly diagnosed pancreatic cancer and 570 controls from 14 Italian centers were studied. Using a standardized questionnaire, all were interviewed personally about their smoking habits, as well as habitual alcohol, coffee, and tea consumption throughout their lives prior to clinical onset of the disease. Details were also obtained on exposure to potential occupational carcinogens. A moderate association, statistically significant only in women (odds ratio, 2.18; 95% confidence interval, 1.30-3.68), was found between pancreatic cancer and cigarette smoking, but none was observed with alcohol or tea consumption or with any particular occupational exposure. Consumption of 1 or 2 cups of coffee per day was not associated with increased risk; 3 coffees per day increased the risk, but not significantly (odds ratio, 1.49; 95% confidence interval, 0.97-2.30); with consumption of more than 3 coffees per day the increase in risk was highly significant (odds ratio, 2.53; 95% confidence interval, 1.53-4.18). A statistically significant dose-response relationship (p < 0.001) was observed in each sex. The association between coffee use and pancreatic cancer still held after controlling for potential confounding factors such as cigarette smoking or alcohol use, and when the analysis was restricted to nonsmoking coffee drinkers. The results of this study, one of the largest of its type so far published, suggest that a causal relationship may exist between coffee consumption and pancreatic cancer.

Intraductal papillary-mucinous neoplasm of the pancreas. A clinicopathologic entity

AIMS

The main clinicomorphologic findings from two new cases of intraductal papillary-mucinous neoplasm of the pancreas were analyzed and discussed.

METHODS

Formalin-fixed pancreatic tissues from the more representative areas were routinely stained. An electron microscopic examination was performed in case 2 on glutaraldehyde-fixed tissue fragments.

RESULTS

Both patients had a long history of symptoms that was suggestive of chronic pancreatitis. At endoscopic retrograde pancreatography a dilatation of the main duct was observed. Ultrasonography revealed cystic dilatations that were interpreted as pseudocysts. The patients underwent total pancreatectomy. The gross appearance showed no mass, but the pancreas was enlarged and diffusely hard. The cut surface showed micromacrocysts filled with soft friable tissue and mucus. Histological examination revealed diffuse neoplastic papillary proliferations within ectatic and cystically dilated ducts. The lesions exhibited varying grades of atypia and foci of in situ carcinoma. No clear evidence of invasion or lymph node metastases were observed. The nontumorous pancreas showed diffuse and multiple hyperplastic papillary changes in the ductal tree.

CONCLUSION

The main clinicopathologic findings of intraductal papillary-mucinous neoplasm of the pancreas have been reported. Our study favors the hypothesis that chronic pancreatitis and/or ductal epithelial papillary hyperplasia may play a role in the pathogenesis of this tumor. We have emphasized the cystic appearance and mucinous features of this neoplasm, and so we suggest the use of the term intraductal papillary-mucinous neoplasm.

Alcoholic liver disease in alcoholic chronic pancreatitis: a prospective study

The prevalence and characteristics of alcoholic liver disease (ALD) in patients with alcohol-induced chronic pancreatitis (AICP) are not well defined. Fifty consecutive patients undergoing surgery for AICP were investigated for evidence of ALD. In addition to preoperative functional and imaging assessment of the liver, all had liver biopsy during surgery. Hepatic biopsy results were as follows: 12 patients had normal liver and 10 minimal aspecific changes; of the remaining 28 patients, 7 had liver cirrhosis, 11 showed features of alcoholic hepatitis, 2 had moderate steatosis, 6 extrahepatic cholestasis, and the remaining 2 had a combination of alcoholic hepatitis and cholestasis. Of the 7 patients with cirrhosis, 3 had oesophageal varices and 2 of these developed ascites in the postoperative period; in the remaining patients with ALD, this disease was subclinical. Patients with ALD consumed significantly (p < 0.005) more alcohol than those without ALD. In patients with cirrhosis, the duration of alcohol consumption (mean 27.6 years, range 18-42 years) was significantly longer (p < 0.05) than in patients without ALD (mean 19.7 years, range 8-36 years). The association of ALD with AICP is much more common than previously believed. The fact that AICP occurs earlier than liver cirrhosis and the fact that many patients stop alcohol consumption after the first attacks of pancreatic pain may explain, at least in part, the apparent rarity with which this association has been indicated by previous studies.

CA19-9: the Italian experience

This article reviews studies of the diagnostic value of CA19-9 determination in pancreatic cancer in Italy. Almost all of these studies show that CA19-9 determination has a good sensitivity in the diagnosis of advanced pancreatic cancer and that its diagnostic accuracy is superior to that of the other serum tumor markers currently available. Although data from patients with early pancreatic cancer are limited, they indicate that the diagnostic value of CA19-9 in these patients is low.