Staging of severity and prognosis of acute pancreatitis by computed tomography and magnetic resonance imaging-a comparative study

BACKGROUND

Determination of severity of acute pancreatitis is important to determine prognosis.

AIMS

(1) the staging of acute pancreatitis by computed tomography and magnetic resonance imaging, (2) the correlation of computed tomography and magnetic resonance severity indices and 3) the correlation of magnetic resonance severity index with C-reactive protein, Ranson score, duration of hospitalization and clinical outcome.

PATIENTS

Thirty-five patients (median age: 64 (27-89)) were studied. Twenty-two patients had biliary acute pancreatitis.

METHODS

The following examinations were conducted: (1) computed tomography 48 h, 7 and 30 days after admission, (2) magnetic resonance imaging 7 and 30 days after admission, (3) C-reactive protein and 4) Ranson score. Clinical outcome was determined on a scale 0-3 (0: remission, 1: local complications, 2: systemic complications, 3: death).

RESULTS

Six of 35 patients (17%) had necrotizing acute pancreatitis. Fifteen of 35 patients (43%) had severe acute pancreatitis according to Ranson criteria. A significant correlation was noted between magnetic resonance severity index and C-reactive protein (r=0.419, p<0.005), Ranson score (r=0.431, p<0.05), duration of hospitalization (r=0.497, p<0.01) and clinical outcome (r=0.420, p<0.05). Comparison of the imaging methods showed a significant correlation between magnetic resonance severity index and computed tomography severity index (r=0.887, p<0.01).

CONCLUSION

Magnetic resonance imaging is of comparable diagnostic and prognostic value with computed tomography in the staging of acute pancreatitis.

Bronchial Hyperresponsiveness in Patients with Inflammatory Bowel Disease

Pulmonary complications have been described in patients with inflammatory bowel disease. The aim of this study was to evaluate bronchial hyppersponsiveness (BHR) in patients with Crohn's disease (CD) and ulcerative colitis (UC). Fifteen patients (8 men, 7 women, mean age: 42.20 ± 12.20 years) participated in the study. None of the patients had a prior history of respiratory disease or suffered from other systematic disease. Skin prick tests for common allergens (such as pollens, mites, foods and moulds) were administered to all patients of the study. The control group included 15 healthy volunteers (10 men, 5 women, mean age: 40.33 ± 5.06 years). The skin tests showed that 3 of 15 patients with inflammatory bowel disease were sensitive to common allergens (two patients to mix grasses and one to D. Pteronysinnus). In the control group, one subject was sensitive to D. Pteronysinnus. BHR was estimated after methacholine challenge. The frequency of BHR among the patients with inflammatory bowel disease was 7 of 15 (46.60%), compared with only one in the control group who was positive at the maximum dosage of methacholine (16 mg/dl). Our results indicate that there is an increased frequency of BHR in patients with inflammatory bowel disease.

The significance of the dosage adjustment of octreotide in the treatment of acute pancreatitis of moderate severity

BACKGROUND/AIMS

Octreotide is a novel semisynthetic analogue of somatostatin mainly indicated for acute necrotizing pancreatitis. The aim of the present study was to define its role in the treatment of acute pancreatitis of moderate severity.

METHODOLOGY

One hundred and twenty patients were randomly assigned to three groups of treatment receiving octreotide subcutaneously 100, 200 or 300 micrograms t.i.d. for seven days. Physical examination and biochemical monitoring were performed daily.

RESULTS

No differences were found between the three groups of patients regarding the rate of rebound of leukocytosis and of the elevated serum and urine amylase levels within normal limits. Patients receiving 300 micrograms t.i.d. presented an earlier relief of pain than all others whereas patients receiving octreotide at a dose of either 200 micrograms or 300 micrograms t.i.d. had a shorter duration of hospitalization (12 days) than those receiving octreotide at 100 micrograms t.i.d. (19 days).

CONCLUSIONS

The subcutaneous administration of octreotide in acute pancreatitis of moderate severity might be of little benefit only at a dose of 200 micrograms t.i.d. or 300 micrograms t.i.d. for at least seven days.

An endoscopic study of gastroduodenal lesions induced by nonsteroidal anti-inflammatory drugs

Rheumatoid arthritis (RA) and osteoarthritis (OA) are frequently treated with nonsteroidal anti-inflammatory drugs (NSAIDs). Although NSAIDs are an effective therapy for the pain and inflammation of arthritis, they are associated with serious side effects, particularly ulceration, bleeding, and perforation of the gastrointestinal (GI) tract. In this study, 1826 OA or RA patients who either had been taking NSAIDS for > or =6 months or had been unable to tolerate continuous NSAID use because of adverse GI symptoms or suspected NSAID-related gastroduodenal lesions were examined endoscopically for gastroduodenal lesions and ulcers. At the same time, the patients were asked to rate the severity of any GI symptoms they had been experiencing. Of the total number of patients studied, 817 (44.7%) were OA patients with a mean (+/- SD) age of 55.8+/-12.9 years, and 1009 (55.3%) were RA patients with a mean age of 53.1+/-13.1 years. Clinically significant gastroduodenal lesions were found in 37.1% of patients (n = 678); of these, 24.0% (n = 439) had ulcers. Gastric ulcers were more frequent than duodenal ulcers (14.8% vs 10.2% of patients; P < 0.05), and most gastric ulcers (72.0%) were found in the antrum of the stomach. The prevalence of gastroduodenal ulcers increased with age (P < 0.001), duration of OA (P < 0.001), and duration of current NSAID use (P = 0.019). The prevalence of gastroduodenal ulcers in patients taking NSAIDs for <1 year was 13.8%, compared with a nearly twofold higher prevalence (25.9%) in patients taking NSAIDs for periods of > or =1 year and up to 15 years. The prevalence of gastric ulcers was 32.6% in patients with a history of gastric ulcer but only 13.5% in patients with no GI history (previous gastric ulcer, duodenal ulcer, or upper GI hemorrhage). No relationship was found between the prevalence of gastroduodenal ulcers and sex (men, 22.4%; women, 24.9%) or prevalence of gastroduodenal ulcers and type of arthritic disease (RA, 23.6%; OA, 24.5%). The prevalence of gastroduodenal ulcers increased with the severity of GI symptoms (P = 0.007). These results provide further endoscopic confirmation of the association between NSAID use and gastroduodenal lesions and ulcers and support the contention that safer treatment alternatives to conventional NSAIDs are required.

Cisapride and ranitidine in the treatment of gastro-oesophageal reflux disease--a comparative randomized double-blind trial

Forty patients with gastro-oesophageal reflux disease and oesophagitis, documented by endoscopy (grades I to III by the Savary-Miller classification) were randomized to participate in a comparative double-blind trial to receive cisapride (10 mg q.d.s.) or ranitidine (150 mg b.d.) for an 8-week period. Upper gastrointestinal endoscopy was performed immediately before the entry to the trial and after the 8-week period at the completion of the trial. The evaluable cohort included 37 patients who completed the trial, 18 in the cisapride group and 19 in the ranitidine group. Three patients were withdrawn from the trial; one on ranitidine developed severe anaphylactic reaction, one on cisapride severe dizziness and one on cisapride did not wish to continue on the trial. The results of the trial, regarding symptomatic and endoscopic improvement were comparable in the two groups. Both drugs were effective in controlling symptoms, such as acid regurgitation, retrosternal pain, retrosternal burning, epigastric fullness and discomfort (pain, burning, sense of pressure) and resulted in endoscopic healing of oesophagitis. With few exceptions, symptoms remained in remission 1 month after treatment in the majority of patients. Globally, both drugs were tolerated comparably, and adverse effects other than those which resulted in the withdrawal from the trial were minimal in both groups. The results of this trial indicate that cisapride and ranitidine, although of different pharmacological action, are comparable in their therapeutic effect in symptomatic improvement and endoscopic healing in patients with mild to moderate gastro-oesophageal reflux disease.

Evaluation of [14C]aminopyrine breath test, peripheral clearance of [99mTc]EHIDA, and serum bile acid levels in liver function and disease

The purpose of this study is to evaluate the diagnostic value of the following tests in the assessment of patients with chronic liver disease (CLD) and cholestatic syndrome (CS): (1) aminopyrine breath test, measuring 14CO2 excretion in the expired air, (2) peripheral clearance of [99mTc]EHIDA, and (3) postprandial levels of glycocholic acid (GCA) and glycochenodeoxycholic acid (GCDCA). The results indicate that: (1) 14CO2 2-hr excretion rate is a specific and sensitive marker of liver function, with good correlation with postprandial bile acid levels, [99mTc]EHIDA retention, and the conventional tests of serum albumin and prothrombin time. (2) Peripheral clearance and retention of [99mTc]EHIDA increased in both groups of CLD and CS vs controls, but it does not discriminate between the two. (3) Postprandial bile acids were elevated in CLD, particularly those of GCDCA, whereas GCA levels were significantly elevated in CS compared with CLD. This may be due to increased synthesis and entry into the blood. (4) The combination of [14C]aminopyrine breath test and postprandial levels of GCDCA enhance the diagnostic value, specificity, and sensitivity in the assessment of patients with CLD.

The impact of early or late diagnosis on patient survival in gastric cancer in Greece

The purpose of this study was to investigate the reasons for delayed diagnosis of gastric cancer in the Greek population and correlate survival with early or late diagnosis. We studied 100 patients with gastric cancer proven at endoscopy. Early diagnosis (less than 3 months from the onset of symptoms) was established in 28 patients (28%), while the diagnosis was late (greater than 3 months) in 72 patients (72%). The reasons for late diagnosis were: 1. delayed consultation on the part of the patient, 2. incorrect medical diagnosis at a) initial evaluation, b) radiological evaluation and, as a result, c) failure to refer for endoscopy and biopsy. Patient survival correlated well with tumor resectability, irrespective of early or late diagnosis. In patients with early diagnosis and resectable tumor survival was 9.9 +/- 4.8 months (mean +/- SD) whereas with non-resectable tumor 4.8 +/- 4.0 months (p less than 0.01). In patients with late diagnosis, survival in resectable tumor was 13.5 +/- 11.7 months compared with 8.5 +/- 6.9 months in non-resectable tumor. No correlation was noted between survival and anatomic location of tumor or degree of histologic differentiation. Early diagnosis of gastric cancer is associated with a higher degree of resectability and therefore of better survival.

A comparative clinical trial of duodenal ulcer healing with two regimens of cimetidine: 800 mg once nightly and 400 mg twice daily

The efficacy and safety of two dosage regimens of cimetidine were compared in a single-blind study of 50 adults with endoscopically proven duodenal ulcers. Patients were randomly allocated to receive 800 mg cimetidine taken once nightly or 400 mg cimetidine taken twice daily for 4 weeks. Following 4 weeks' treatment patients again underwent endoscopy and, if healing was incomplete, they received a further 4 weeks' treatment. At 4 weeks, healing occurred in 21/25 (84%) patients on the once-daily regimen and in 15/25 (60%) patients treated twice daily (P less than 0.05). Cumulative healing rates after 8 weeks' treatment were 92% and 96%, respectively. Symptomatic improvement was obtained to the same degree with both regimens. No adverse effects were recorded and laboratory values remained normal during both treatments. The results indicate that cimetidine given as one dose each night was superior to the twice-daily regimen.

Small intestinal function and structure in patients with chronic renal failure

We studied 24 patients with end-stage chronic renal failure not treated with hemodialysis (CRF1) and 16 patients on regular hemodialysis (CRF2), to investigate the digestive, absorptive and morphological aspects of the small intestinal mucosa. Serum d-xylose test and biochemical parameters of absorption (serum calcium and proteins) were determined. Jejunal mucosal biopsies were obtained and tissue homogenates assayed for disaccharidases (sucrase, maltase and lactase) and dipeptidases (glycyl-glycinase, leucyl-glycinase and leucyl-aminopeptidase). Histological changes were classified according to the severity of abnormality and compared with biopsies obtained from control subjects. Serum d-xylose test, calcium and proteins were normal in patients with CRF. Maltase specific activity was higher in CRF1 than in controls (p less than 0.05). Lactase and leucyl-aminopeptidase showed a tendency to decrease in CRF, but this difference did not reach statistical significance. Sucrase, glycyl-glycinase and leucyl-glycinase specific activity in CRF was similar to the control group. Histological changes of the small intestinal mucosa of mild to moderate degree were noted in 68% of patients with CRF vs 36% in control subjects (p less than 0.01). No significant difference was noted in the incidence of absorptive, enzymatic (with the exception of maltase) and histological changes between the two groups of patients with CRF. These changes are not influenced by hemodialysis, a long-term treatment averaging 6 months, they appear to represent primary manifestations of CRF and may be related to the nutritional status of patients with CRF.

Disseminated strongyloidiasis with uncommon manifestations in Greece

Strongyloidiasis is a human intestinal parasitosis caused by the nematode Strongyloides stercoralis. In most cases the infection is subclinical, but rarely, disseminated strongyloidiasis may occur in debilitated or immunocompromised patients, and in those who receive immunosuppressive agents. In this report, we describe an unusual case of severe disseminated strongyloidiasis, with intestinal, pulmonary and neurological manifestations, in a previously healthy male. The onset of the disease was acute with headache and neck stiffness, due to subarachnoid-ventricular haemorrhage. During a protracted clinical course the patient developed diarrhoea, abdominal pain, recurrent paralytic ileus, pneumonitis and respiratory distress, malabsorption and weight loss, diagnosis was delayed due to the complicated course and rarity of the disease. The diagnosis finally established during evaluation for malabsorption by demonstrating larvae of S. stercoralis in the jejunal mucosal biopsy and faeces. Response to mebendazole treatment was prompt with complete recovery and resolution of all systemic manifestations. Early diagnosis and treatment of strongyloidiasis in the intestinal phase is critical in the prevention of dissemination, which may prove lethal due to life-threatening complications.

Prophylactic treatment with cimetidine after renal transplantation

17 consecutive patients who underwent renal transplantation during the period 1979-1981 and were at risk of gastrointestinal hemorrhage were treated prophylactically with the histamine H2-blocker cimetidine without antacids. The incidence of gastrointestinal bleeding, the number of rejection episodes and graft survival were compared with 17 patients, who had received renal transplant during the period 1976-1978 and had not received cimetidine. The incidence of gastrointestinal hemorrhage was not reduced in the cimetidine-treated patients. In addition, cimetidine treatment neither increased the total number of rejection episodes nor changed the long-term graft survival. The results of this study indicate that cimetidine does not appear to be superior to antacids in the prevention of gastrointestinal bleeding in renal transplant recipients.

Diagnostic value of serum ferritin in primary hepatocellular carcinoma

The diagnostic value of serum ferritin levels was evaluated in 19 patients with biopsy-proven primary hepatocellular carcinoma (PHC) and 26 patients with chronic liver disease (CLD). Serum ferritin levels were significantly elevated in PHC, as compared with CLD and controls (p less than 0.0005). Similarly, serum ferritin/SGOT ratio, an index of increased ferritin production, was significantly higher in PHC than in CLD and controls. Serum alpha-fetoprotein (alpha-FP) was higher in PHC than in CLD (p less than 0.0025). No significant correlation was noted between serum ferritin and alpha-fetoprotein or SGOT in PHC and CLD. 17 of 19 patients with PHC had serum ferritin values over 450 ng/ml (sensitivity 88%). By contrast, only 10 of 17 patients with PHC (59%) demonstrated alpha-FP levels over 25 ng/ml, compatible with the diagnosis of PHC. 9 of these 10 patients had ferritin levels over 450 ng/ml, within the distribution of values for PHC. Conversely, 7 of 17 patients with PHC (40%) had normal levels of alpha-FP (false-negative). However, 6 of these patients (86%) had ferritin levels over 450 ng/ml, consistent with values in PHC. In this study, the overall sensitivity of serum ferritin in PHC was higher than that of alpha-FP (88 versus 59%) and its specificity 85 versus 68% for alpha-FP. These data indicate that serum ferritin may be utilized as a useful diagnostic marker in the evaluation of patients with PHC.

Intestinal digestion of dipeptides in experimental diabetes in the rat

Intestinal digestion of two dipeptides, leucyl-leucine and phenylalanyl glycine was studied in vivo in diabetic and control rats utilizing the segmental perfusion technique. Both proximal and distal segments of the small intestine were perfused with 20 mM of each substrate with 140 mM NaCl and 0.5% polyethylene glycol. There was no statistically significant difference in the rates of luminal disappearance (hydrolysis) of the two dipeptides between the control and diabetic animals.

Diet therapy in gastrointestinal disease: a commentary

Dietary regimens in gastrointestinal disease can be divided into two categories: First, those of proven value include: (a) Disaccharide elimination for disaccharidase deficiency and exclusion of monosaccharides for sugar malabsorption; (b) gluten-free diet for celiac/sprue; (c) elimination of certain allergens because of food allergies; (d) protein restriction for portal systemic encephalopathy; (e) low-carbohydrate diet for dumping syndrome; (f) low-fiber diet for diarrheal syndromes; and (g) low-fat diet for steatorrhea. Second, controversial diets include a bland diet for acid-peptic disorders, a high-fiber diet for colonic disorders, and a low-fat diet for gallbladder disease. It is important to separate facts from fancy in the dietary management of patients with gastrointestinal disease and base the recommendations for a particular diet on available objective evidence, not on traditional or fashionable trends.

A possible association of pernicious anemia with neoplasia

7 out of 39 patients with pernicious anemia developed 9 different neoplasms during a period of 3--20 years after the diagnosis of pernicious anemia. These primary neoplasms originated from the lymph nodes, larynx, colon, stomach, kidney, meninges, maxillary sinus and eighth nerve. Treatment with vitamin B12 did not influence the development of tumor. Statistical analysis showed that the observed incidence of 9 neoplasms in this group was significantly higher than the expected 3.3 cases during the aggregate follow-up period (p = 0.002). Although a higher incidence of neoplasms in patients with other underlying diseases does not necessarily indicate an association, a high degree of suspicion for neoplastic disease is justifiable in patients with pernicious anemia.

Abnormalities of jejunal mucosal enzymes in ulcerative colitis and Crohn's disease

Jejunal mucosal function and structure was examined in 31 patients with ulcerative colitis and 29 patients with Crohn's disease with ileal, ileocolonic or colonic involvement; A significant reduction of the specific activity of disaccharidases (lactase, sucrase and trehalase) in jejunal mucosal homogenate occurred in patients with inflammatory bowel disease. Similarly, alkaline phosphatase was reduced in ulcerative colitis. Several dipeptidases such as glycyl-leucine, leucyl-glycine, glycyl-glycine and valyl-proline hydrolase activities were lower in patients with inflammatory bowel disease than in controls. Histological changes in jejunal mucosal biopsies occurred in 71% of patients with ulcerative colitis and 61% with Crohn's disease. These changes ranged from mild abnormalities of villus architecture to marked reduction of villus height. Most patients with a reduction in mucosal enzymes had concommitant morphological changes in jejunal mucosal biopsy. The results of this study indicate that functional and structural abnormalities of the jejunal mucosa frequently occur in patients with inflammatory bowel disease without radiologic evidence of proximal small bowel involvement.

Functional and morphological abnormalities of the small intestinal mucosa in pernicious anemia--a prospective study

Small intestinal mucosal function and structure was investigated in 13 patients with pernicious anemia prior to and after treatment with vitamin B12. Histological abnormalities of the jejunal mucosa were shortening of villi of varying degree, increased infiltrate of the lamina propria with monocytes and plasma cells and megalocytosis of the absorptive epithelial cell. Malabsorption of d-xylose occurred in 45%, fat in 30%, vitamin B12-IF complex in 69%, hypocarotinemia in 23% and hypoalbuminemia in 30% of the patients. By contrast, digestive brush border enzymes, i.e. disaccharidases, alkaline phosphatase and leucyl-naphthylamidase were not altered in pernicious anemia. Patients with significant jejunal mucosal abnormalities and decrease of the absorptive surface demonstrated malabsorption of one or more nutrients. Morphological and functional abnormalities were restored to normal after treatment with vitamin B12, suggesting that small intestinal changes in pernicious anemia constitute primary systemic manifestations.

Diagnosis of exocrine pancreatic insufficiency in cystic fibrosis by the synthetic peptide N-benzoyl-L-tyrosyl-p-aminobenzoic acid

The synthetic peptide N-benzoyl-L-tyrosyl-p-aminobenzoic acid is specifically cleaved by chymotrypsin to Bz-Ty and PABA. The liberated PABA is absorbed and excreted in the urine. Accordingly, PABA recovery reflects intraluminal chymotrypsin activity and is an index of exocrine pancreatic function. This test was evaluated in 24 patients with cystic fibrosis to determine its role in the diagnosis of exocrine pancreatic insufficiency. Cumulative percent PABA recovery in six hours was significantly lower in CF patients compared with the control group. No overlap was noted between the two groups. There was good correlation between PABA recovery, fecal chymotrypsin activity, and coefficient of fat absorption. These findings indicate that PABA recovery is significantly reduced in patients with CF and steatorrhea and may prove a practical and reliable test of pancreatic insufficiency.

Effect of alloxan-induced diabetes on intestinal peptidases in the rat

Intestinal transport of amino aicds, similar to sugar absorption, is enhanced in experimental diabetes. Because peptidases play a significant role in peptide digestion, we examined the effect of diabetes on intestinal peptidases. Leucyl-naphthylamidase and leucyl-glycine hydrolase (brush border peptidases) and prolyl-glycine hydrolase (cytosol peptidase) were assayed in the brush border and cytosol fraction in diabetic rats 7 days after alloxan administration. Mucosal weight, protein concentration, and total and specific activity of leucyl-naphthylamidase and leucyl-glycine hydrolase were significantly increased in diabetes in the brush border but not in cytosol fraction. By contrast, prolyl-glycine hydrolasw was not affected in cytosol fraction or brush border. These data indicate that brush border peptidases are increased in experimental diabetes. This adaptive response of the small intestinal mucosa is similar to disaccharidase elevation and alteration in the intestinal absorptive function which occurs in experimental diabetes.

Secretory immunoglobulin deficiency in a family with inflammatory bowel disease

A family with 4 of 10 first-degree relatives affected with inflammatory bowel disease (IBD) was studied to determine whether any distinct immunological abnormalities occur in the affected members, as compared with unaffected members of the family, normal controls, and other unrelated patients with IBD. Red cell blood type and HL-A phenotypes did not distinguish between healthy and affected members, although HL-A2, 32, B27, and B12 were the predominant haplotypes in members with IBD. There was no significant difference between the two groups in the lymphocyte subpopulation counts of T cells, B cells, and cells carrying Fc or complement receptors. The in vitro mitogen response, however, to phytohemagglutinin and pokeweed mitogen were depressed in the affected members. Serum IgA and C3 levels were significantly elevated in members with IBD compared to healthy subjects with values of 232 +/- 69 (mean +/- SD) versus 148 +/- 29 mg per dl for IgA (P less than 0.05) and 173 +/- 32 versus 115 +/- 22 mg per dl for C3 (P less than 0.025), respectively. Plasma and, to a lesser extent, peripheral lymphocytes from 2 affected members who were tested were cytotoxic to allogeneic colonic epithelial cells. Salivary IgA was normal in the affected family members and unrelated patients with IBD. However, the free secretory component of salivary IgA was absent or markedly depressed in family members, as well as in unrelated patients with ulcerative colitis. This deficiency of the secretory immune system appears to characterize more frequently ulcerative colitis than Crohn's disease and may compromise mucosal host defenses in IBD.

Characterization of p-aminobenzoic acid transport across the rat intestine

The intestinal absorption of PABA, a member of the vitamin B complex, was characterized in vivo and in vitro in the rat by the segmental intestinal perfusion and everted gut sac technique. Net PABA absorption was directly proportional to substrate concentration, and saturation of absorption did not occur with increasing concentrations of PABA (1 to 50 mM), indicating a nonsaturable process. Jejunal and ileal absorption rates were similar and were not influenced by the presence of glucose or the absence of sodium in the test solution. Similarly, 14C-PABA transport in vitro was nonsaturable and proportional to PABA concentration (0.05, 0.5, 1, 10, and 50 mM). It was not inhibited by ouabain or other PABA analogues such as folic acid and benzoic acid. These studies indicate that PABA, a vitamin B cofactor, is absorbed by a nonsaturable, sodium-independent process, which characterizes passive diffusion and is similar to the absorption of other vitamin B members.

Effect of pancreatic duct ligation on exocrine pancreatic function and structure in the rabbit

4 weeks after pancreatic duct ligation in the rabbit, fecal and luminal chymotrypsin were detected in concentrations similar to the control group. Pancreatic changes in the ligated group were marked dilatation of the main pancreatic duct, proliferation and distention of ductules and fibrosis. Despite pancreatic duct ligation and fibrosis, proteolytic enzymes continued to secrete into the duodenal lumen. These results suggest that pancreatic duct ligation in the rabbit is not associated with total pancreatic insufficiency.

Laboratory aids in the diagnosis of pancreatitis

The diagnosis of both acute and chronic pancreatitis continues to be a challenge despite the development of new techniques and the refinement of old methods. The problem is best approached by the application of a combination of tests which can provide a reasonable degree of sensitivity and specificity applicable to the different forms of pancreatitis. In acute pancreatitis an elevation of serum amylase and amylase/creatinine clearance ratio is diagnostically useful. In chronic pancreatitis, several tests are needed to enhance the diagnostic yield, and such tests can include the secretin-pancreozymin test, ERCP, fecal fat measurement, Lundh test meal, and the administration of the synthetic peptide BZ-Ty-PABA.

Lactase deficiency--a comparative study of diagnostic methods

The diagnostic value of 1-14C-lactose breath test was compared with the standard lactose tolerance test and lactase assay in jejunal biopsies in 16 control subjects, 14 patients with lactase deficiency (LD) proven by lactase assay and 20 patients with irritable bowel syndrome (IBS). 14CO2 specific activity in the 2-hr breath collection after administration of 1-14C-lactose (5 muCi) provided a satisfactory separation between the control and LD group. Values were 7.0 +/- 2.0% dose administered/mmoles 14CO2 X 10(-3) (mean +/- SD) in the control group versus 2.1 +/- 1.5 in LD (P less than 0.001) versus 4.9 +/- 2.3 in IBS (P less than 0.01). 1-14C-lactose breath test was superior to standard lactose tolerance test in specificity (P less than 0.05) and provided a satisfactory correlation between 14C-lactose absorption and lactase assay (r = 0.77). The prevalence of LD in IBS was 40% by the breath test and 35% by lactase assay, suggesting that lactose malabsorption may play a role in the symptoms in the population of some patients with IBS. It appears that 1-14C-lactose breath test is a sensitive, specific and accurate method for the diagnosis of LD in clinical practice and suitable for large scale epidemiological surveys.

Recurrent colonic ulcers in celiac sprue, an unrecognized fatal complication: report of a case

In a patient who had celic sprue intractable to a gluten-free diet, volvulus and jejunal and colonic ulcers developed. Following segmental colonic resection, these ulcers recurred at the site of the previous anastomosis, and proved a fatal complication because of colonic perforation. Since no obvious etiology of colonic ulcers could be identified in this case, it is possible that they may represent an unrecognized intestinal complication of celiac sprue similar to jejunoileal ulcers.

Effect of aspirin on intestinal absorption of glucose, sodium, and water in man

The effect of aspirin on small intestinal function in six healthy volunteers was examined using a segmental perfusion technique, with a test solution of 40 mM D-glucose, 140 mM NaCl, and 0-5% polyethylene glycol. Jejunal glucose, sodium, and water absorption rates were inhibited by 50% after oral administration of 2-6 g aspirin. Adenosine triphosphate (ATP) concentration was assayed in jejunal mucosal biopsies before and after aspirin. There was an almost 50% decrease in mucosal ATP levels after aspirin. This effect may be mediated through cellular injury and impairment of mitochondrial energy metabolism. These data suggest that aspirin may significantly alter small intestinal function. It appears possible that the inhibitory effect of aspirin on glucose absorption may account, at least in part, for the lower blood sugar levels observed with the use of the drug.

Treatment of toxic megacolon. A comparative review of 29 patients

A review of 29 patients with toxic megacolon complicating ulcerative colitis was undertaken to (1) compare the results of medical and surgical treatment; (2) determine the optimal timing for surgical intervention, and (3) identify possible precipitating factors. Twenty-one patients were treated medically with nasogastric suction, steroids, parental fluids, blood transfusions, and antimicrobial agents. Of the 21 patients, 11 (53%) showed improvement by subjective and objective criteria and 10 (47%) failed to respond. Sixteen patients were treated surgically. This group was subdivided into 8 patients who failed to respond to medical treatment and 8 treated surgically. Total proctocolectomy with ileostomy was performed in 8 and subtotal colectomy and ileoproctostomy in 8, with subsequent proctectomy and ileostomy in 6 patient. Six of 8 patients (75%) treated primarily surgically improved, and 2 (25%) died. Seven of 8 patients (87.5%) treated surgically after failure of medical trial showed definite postoperative improvement, and 1 (12.5%) failed. Those who were operated on within the first 48-72 hr after the diagnosis of toxic megacolon was made responded uniformly well. Anticholinergics, opiates,, barium enema, and colonoscopy were identified as possible precipitating factors in 70% of cases. The results of this tudy in this patient population indicate that early surgical therapy in toxic megacolon is associated with better results than medical therapy (P less than 0.025). Although intensive, optimal medical therapy plays a significant role in the management of toxic megacolon, failure to induce rapid improvement within 48-72 hr constitutes an indication for definitive surgical treatment.

The role of metoclopramide in peroral jejunal biopsy: a controlled randomized trial

Metoclopramide is known to enhance gastric emptying and stimulate duodenal and small-intestinal peristaltic activity. The effect of the drug on peroral jejunal biopsy was examined in a controlled, double-blind, randomized trial. Forty-nine patients (24 females and 25 males) who required jejunal biopsy for diagnostic purposes were admitted to the study. All the biopsies were performed by the same operator using the Quinton multipurpose suction biopsy tube and applying the same technique. Twenty-four patients ranging in age from 18 to 67 years (mean 44.5) received placebo intravenously (sodium metabisulfite), and 25 patients from 16 to 73 years old (mean 39.9) received 10 mg of metoclopramide intravenously prior to the jejunal intubation. Objective parameters of the study were (1) time in minutes required for the intubation at the biopsy site, ie, the area at the ligament of Treitz, and (2) fluoroscopy time. Intubation time in the placebo group was 22.3 +/- 1.9 min (mean +/- SEM) vs 11.3 +/- 1.4 min in the metoclopramide group (P less than 0.001). Fluoroscopy exposure time was 2.47 +/- 0.25 in the placebo group vs 1.40 +/- 0.12 min in the metoclopramide group (P less than 0.001). Subjective clinical evaluation of the operator's assessment of the procedure was based on a 0-4 scale (much easier = 0, easier = 1, average = 2, harder = 3, and much harder = 4). Metoclopramide administration resulted in a significantly easier performance of the procedure (P less than 0.001) but did not influence patient tolerance. Three patients who received metoclopramide and one receiving placebo developed mild to moderate drowsiness of short duration. The results of this controlled trial indicate that metoclopramide significantly shortens the time required for jejunal biopsy and reduces fluoroscopy exposure. Its regulatory action on gastrointestinal motility contributes to the easier performance of a valuable diagnostic procedure.

Digestion of tripeptides and disaccharides: relationship with brush border hydrolases

Intestinal digestion of two tripeptides (leucyl-glycyl-glycine, prolyl-glycyl-glycine) and two disacchrarides (sucrose, maltose) was examined in the hamster by intestinal perfusion in vivo and hydrolysis of the substrates by microvillus membranes. Perfusion studies showed that luminal disappearance rates of leucyl-glycl-glycine were significantly higher than prolyl-glycyl-glycine (P less than o.001), sucrose (P less than 0.001), and maltose (P less than 0.005). Hydrolytic products of leucyl-glycyl-glycine, sucrose, and maltose were detected in the gut lumen in appreciable concentrations, whereas negligible concentrations of prolyl-glycyl-glycine products were present. Leucyl-glycyl-glycine hydrolysis in microvillus membranes was markedly higher than prolyl-glycyl-glycine (P less than 0.001), which was predominant in the cytoplasmic fraction. These results indicate that leucyl-glycyl-glycine, like sucrose and maltose, is hydrolyzed at the membrane. With some tripeptides, i.e., leucyl-glycyl-glycine, digestion occurs at the microvillus membrane with subsequent transport of hydrolytic products into the intestinal epithelial cell. Other tripeptides, i.e., prolyl-glycyl-glycine, may cross the membrane and undergo intracellular hydrolysis by cytoplasmic peptidases.

Intestinal digestion and absorption of sucrose in experimental diabetes

Intestinal sucrose hydrolysis and absorption of monosaccharide products was studied in vivo utilizing the segmental perfusion technique in diabetic and control rats. The proximal jejunum was perfused with 20 mM sucrose, 140 mM NaCl and 0.5% PEG with 14C-PEG, as the nonabsorbable marker. Rates of sucrose hydrolysis and adsorption of monosaccharide products (fructose, and glucose) were determined. There were no statistically significant differences between the diabetic and control rats. This indicates that the previously reported increase in sucrase activity in diabetes does not correlate with enhanced rates of sucrose hydrolysis. Several possibilities for the interpretation of these results are discussed.

Achalasia of the esophagus. A reappraisal of esophagomyotomy vs forceful pneumatic dilation

56 patients with achalasia of the esophagus were reviewed in a retrospective study to compare the results of a forceful pneumatic dilation with those of a Heller esophagomyotomy. 22 of 33 patients treated with forceful dilation (67%), showed relief of dysphagia and reduction in the average esophageal diameter by barium swallow during the follow-up period (mean = 6.5 years). In 2 patients (6%), forceful dilation was complicated by esophageal perforation, promptly diagnosed, and successfully treated at surgery in both patients. 21 out of 23 patients who underwent esophagomyotomy (91%) showed permanent relief of symptoms and improvement by endoscopic and radiographic criteria. There were no significant postoperative complications during the follow-up period ranging between 1.5 and 10.0 years. The results of this study indicate that esophagomyotomy constitutes a more effective therapeutic modality than forceful dilation (P less than 0.05). Although esophageal dilation has a place in the treatment of early achalasia, esophagomyotomy appears to be a safer and a more successful form of treatment, of particular value in advanced esophageal disease and in those instances where pneumatic dilation fails to result in immediate clinical improvement.