Characterization of novel PNLIP variants in congenital pancreatic lipase deficiency

BACKGROUND/OBJECTIVES

Studies of a rare homozygous missense mutation identified in two brothers diagnosed with congenital pancreatic lipase deficiency (CPLD) provided the first definitive evidence linking CPLD with missense mutations in the gene of PNLIP. Herein, we investigated the molecular basis for the loss-of-function in the three novel PNLIP variants (c.305G > A, p.(W102∗); c.562C > T, p.(R188C); and c.1257G > A, p.(W419∗)) associated with CPLD.

METHODS

We characterized three novel PNLIP variants in transfected cells by assessing their secretion, intracellular distribution, and markers of endoplasmic reticulum (ER) stress.

RESULTS

All three variants had secretion defects. Notably, the p.R188C and p.W419∗ variants induced misfolding of PNLIP and accumulated as detergent-insoluble aggregates resulting in elevated BiP at both protein and mRNA levels indicating increased ER stress.

CONCLUSIONS

All three novel PNLIP variants cause a loss-of-function through impaired secretion. Additionally, the p.R188C and p.W419∗ variants may induce proteotoxicity through misfolding and potentially increase the risk for pancreatic acinar cell injury.

Association between chronic asymptomatic pancreatic hyperenzymemia and pancreatic ductal anomalies: a magnetic resonance cholangiopancreatography study

PURPOSE

Elucidating the association between pancreatic ductal anomalies and chronic asymptomatic pancreatic hyperenzymemia using magnetic resonance cholangiopancreatography.

METHODS

We conducted a single-center, retrospective, case-control study. The healthy community group comprised 554 subjects who participated in a paid, whole-body health checkup program. The patient group comprised 14 subjects with idiopathic pancreatic hyperamylasemia or hyperlipasemia. All subjects underwent magnetic resonance cholangiopancreatography. The clinical features and incidence rates of pancreatic ductal anomalies were then compared between the groups.

RESULTS

Compared to the healthy community group, the patient group was significantly more likely to be ≥ age 65 (71.4% of patient group vs. 22.1% of healthy community group), have a history of diabetes mellitus (21.4% vs. 5.4%) or hypertension (35.7% vs. 11.4%), and to have pancreas divisum (21.4% vs. 2.7%), meandering main pancreatic duct (21.4% vs. 4.1%), Wirsungocele (14.3% vs. 1.1%), or dilated main pancreatic duct (14.3% vs. 2.3%). Multivariate analysis found that age ≥ 65 (odds ratio 8.76), presence of pancreas divisum (odds ratio 13.2), meandering main pancreatic duct (odds ratio 8.95), and Wirsungocele (odds ratio 17.6) were independent factors significantly associated with chronic asymptomatic pancreatic hyperenzymemia.

CONCLUSIONS

Pancreas divisum, meandering main pancreatic duct, and Wirsungocele were independently associated with chronic asymptomatic pancreatic hyperenzymemia.

Chronic Asymptomatic Pancreatic Hyperenzymemia (CAPH): Meta-analysis of pancreatic findings at second-level imaging

BACKGROUND/OBJECTIVES

Data estimating the prevalence of significant findings during the investigation of patients with Chronic Asymptomatic Pancreatic Hyperenzymemia (CAPH) are scanty and heterogeneous, and the diagnostic approach is therefore uncertain. The aim of this study was to meta-analyze pancreatic abnormalities detected at second-level imaging in patients with CAPH.

METHODS

Pubmed database was searched until September 2018 for articles evaluating CAPH patients through MRI-Cholangio-Pancreatography with/without secretin (MRCP or s-MRCP) or Endoscopic Ultrasound (EUS). The methodology was developed from PRISMA checklist. Pooled prevalences of pancreatic findings were calculated, with subgroup analyses according to imaging modality. Quality of the studies, publication bias and heterogeneity were analyzed.

RESULTS

In 8 articles describing 521 patients with CAPH, pooled prevalence of normal imaging was 56.6% [95%CI (CI) 41.9-70.2; I² = 88.6%). Prevalences of neoplasia, chronic pancreatitis, pancreatic cysts and benign abnormalities were 2.2% [CI1.2-4.1; I² = 0%], 16.2% [CI10.2-24.8; I² = 71.5%], 12.8% [CI8.2-19.3; I² = 64.7%] and 17.2% [CI11.9-24.2; I² = 71.5%] respectively. In sub-analyses, EUS and s-CPRM were less frequently normal and diagnosed more "early" chronic pancreatitis, while neoplastic lesions were still rare.

CONCLUSIONS

In CAPH patients, second-level pancreatic imaging is normal in 56% of the cases, neoplastic lesions are rare and the rate of pancreatic cysts is similar to that seen as incidental findings. More than one third of patients are diagnosed with abnormalities whose prognostic significance is uncertain. Despite the superior sensitivity of EUS or s-CPRM, the less costly/invasive and more available contrast-enhanced MRCP does not seem to miss relevant findings in this setting.

Healthy Chinese with benign pancreatic hyperenzymemia

Benign pancreatic hyperenzymemia, or Gullo's syndrome, is an uncommon syndrome characterized by a long-term increase of serum pancreatic enzyme in the absence of pancreatic diseases. It is primarily discovered incidentally and occurs in either sporadic or familial form. Herein, we report the first case of benign pancreatic hyperenzymemia in Taiwan. A 57-year-old Chinese male was incidentally noted with elevated serum amylase and lipase levels during a health check-up and was diagnosed with benign pancreatic hyperenzymemia using a series of image and serological tests. Although this is the first case of benign pancreatic hyperenzymemia in Taiwan, its prevalence may be underestimated due to the diagnostic difficulties. Correct diagnosis of this disease is important to avoid costly test duplication, unfounded anxieties, and multiple consultations.

Serum enolase: a non-destructive biomarker of white skeletal myopathy during pancreas disease (PD) in Atlantic salmon Salmo salar L

Diseases which cause skeletal muscle myopathy are some of the most economically damaging diseases in Atlantic salmon, Salmo salar L., aquaculture. Despite this, there are limited means of assessing fish health non-destructively. Previous investigation of the serum proteome of Atlantic salmon, Salmo salar L., during pancreas disease (PD) has identified proteins in serum that have potential as biomarkers of the disease. Amongst these proteins, the enzyme enolase was selected as the most viable for use as a biomarker of muscle myopathy associated with PD. Western blot and immunoassay (ELISA) validated enolase as a biomarker for PD, whilst immunohistochemistry identified white muscle as the source of enolase. Enolase was shown to be a specific marker for white muscle myopathy in salmon, rising in serum concentration significantly correlating with pathological damage to the tissue.

Nonspecific hyperamylasemia: a case report

CONTEXT

The elevation of serum amylase and lipase are generally associated with pancreatic diseases. However they can be associated with different pathologies unrelated with amylase and lipase.

CASE REPORT

This paper aims to report a case of a patient diagnosed with nonspecific hyperamylasemia and warn of this possibility in the differentiation of hyperamylasemia.

CONCLUSION

The correct diagnosis of silent hyperamylasemia is important in order to determine whether there is the risk of pancreatic disease or if we are just ahead of a benign hyperenzymemia.

[Pancreatic hyperenzymemia: new advances in the field of clinical-diagnostic approach, with particular attention about Gullo's syndrome]

An increase in serum levels of pancreatic enzymes is a well-known manifestation of pancreatic disease, especially of inflammatory or neoplastic nature, even if several extrapancreatic diseases can equally cause that increase. In addition to this pathological type of hyperenzymemia, different "non-pathological" forms have also been identified, including macroamylasemia, salivary, and mixed salivary and pancreatic hyperamylasemia, in all of which only amylase elevations are seen. Nevertheless, in 1996 a new syndrome characterized by an abnormal, chronic, benign increase in levels of serum amylase, pancreatic isoamylase, lipase and trypsin, asymptomatic and usually discovered incidentally, was described for the first time by Lucio Gullo et al. Hyperamylasemia/hyperlipasemia's observation is nowadays on the increase because general practitioners tend to include more frequently amylase and lipase in routine blood tests and, moreover, because the constant evaluation of this biochemical alteration in the Emergency Unit: for this reason, this syndrome was clearly identified only recently. Therefore, it's characterized by serum elevation of all pancreatic enzymes in the absence of underlying diseases; it occurs in either sporadic or familial form and it persists over time with considerable fluctuation in serum enzyme concentrations, including frequent normalizations. Proper diagnosis of this form of hyperenzymemia is important because it reassures the subjects having this anomaly that the syndrome is benign, and because it can prevent multiple and expensive diagnostic tests or useless hospitalizations or therapies.

Amylase, pancreatic isoamylase and lipase in serum before and after endoscopic pancreatography

Serum amylase, isoamylase and lipase were determined in 17 patients with pancreatic or biliary diseases before and after endoscopic retrograde pancreatography (ERP). Within 1/2-2 hours after cannulation of the pancreatic duct, serum lipase was increased to approximately 4 times the upper reference level and normalized almost completely at 24 hours. A much smaller increase was found in amylase and isoamylase. The elevation in enzyme activities was less in patients with abnormal than with normal ERP. The results suggest that lipase is a more sensitive indicator of pancreatic injury than amylase and isoamylase.

Serum angiotensin converting enzyme levels in pancreatic diseases

BACKGROUND/AIMS

Recently, the existence of a local renin angiotensin system (RAS) in the pancreas has been demonstrated in laboratory animals as well as in human. It has been suggested that RAS and angiotensin converting enzyme (ACE) activity increase in diseases involving pancreas tissue. In the present study, we analyzed the relationship between serum ACE levels and pancreas disorders including acute and chronic pancreatitis, and pancreas adenocancer.

METHODOLOGY

The study groups comprised 14 cases with acute pancreatitis (male/female: 5/9), 38 chronic pancreatitis patients (male/female: 25/13) and 21 pancreas adenocancer cases (male/female: 11/10). The ACE activity in the sample was determined by comparing the sample reaction rate to that obtained with the ACE calibrator.

RESULTS

Serum ACE levels were 38.28 +/- 23.67 U/L (10-108), 43.71 +/- 23.58 UL (7-120), 39.14 +/- 19.31 U/L (5-77) and 38.04 +/- 13.69 U/L for patients with acute pancreatitis, chronic pancreatitis, pancreas cancer and healthy controls respectively. Serum ACE levels were not significantly different among all groups (p>0.05). There was no significant difference regarding ACE levels in patients with metastasis and without metastasis. There was no correlation between ACE levels and tumor size.

CONCLUSIONS

Our results showed that serum ACE levels increased in neither benign nor malignant pancreas diseases. However, serum ACE levels may not reflect the actual RAS activity because non-ACE pathways affecting RAS activity have been described. Further studies analyzing non-ACE pathways contributing to RAS activity in human pancreatic disorders are needed.

[Benign pancreatic hyperenzynemia or Gullo's syndrome]

Benign pancreatic hyperenzymemia is a newly identified syndrome characterized by abnormal increase in serum pancreatic enzymes in 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 paper the main characteristics of this syndrome are described.

Occult pancreaticobiliary reflux in gallbladder cancer and benign gallbladder diseases

BACKGROUND AND OBJECTIVES

It was proposed that occult pancreaticobiliary reflux (OPBR) was associated with precancerous mucosal changes in the gallbladder, hence the importance of this disorder. There are no published reports investigating the incidence of OPBR in patients operated on for the entire spectrum of benign gallbladder diseases and gallbladder cancer. Our aim was to determine the incidence of OPBR and measure the levels of active pancreatic enzymes (amylase and lipase) in gallbladder bile of patients undergoing cholecystectomy for benign and malignant gallbladder diseases.

METHODS

One hundred eight patients with normal pancreaticobiliary junction evidenced by operative cholangiography were included in the study.

RESULTS

According to gallbladder bile amylase and lipase levels, 84.2% and 89% patients respectively had OPBR. OPBR was present in all gallbladder cancer patients; in these patients the biliary levels of amylase and lipase were significantly higher than the levels found in patients with benign gallbladder pathology (P < 0.0001).

CONCLUSIONS

OPBR could lead to inflammatory changes of the biliary epithelium and progress towards the development of precancerous mucosal changes and gallbladder cancer. The reason why such high levels of pancreatic enzymes are regurgitated into the biliary tree of patients with gallbladder cancer should be clarified.

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 patient with slightly elevated pancreatic enzymes and abdominal complaints

Abdominal complaints in combination with slightly elevated serum pancreatic enzymes represent a classical clinical challenge. These symptoms may be due to coincidental unrelated harmless disorders, benign pancreatic alterations which are fairly easily treatable such as mild acute pancreatitis or uncomplicated chronic pancreatitis. However, serious, often insidious diseases such as pancreatic tumours may also present with this constellation as their first signs. Diagnostic procedures need to be stratified according to acuteness and severity of symptoms. While patients with acute onset of symptoms and severe complaints need immediate and combined laboratory and imaging investigations to allow adequate therapy, chronic and mild complaints usually justify a stepwise diagnostic approach consecutively using abdominal ultrasound, CT/MRI and endoscopic ultrasound as imaging procedures and reserving ERCP for cases which remain unclear or in which interventional therapy is needed. Diagnosis and follow-up are often particularly demanding in patients with cystic tumours of the pancreas. In chronic pancreatitis patients pain therapy and adequate control of pancreatic exocrine insufficiency may pose major problems. Patients with refractory pain may ultimately require surgical intervention. Another important indication for surgery in chronic pancreatitis is suspicion of cancer that cannot be ruled out by dedicated diagnostic procedures. This also applies to cystic tumours of the pancreas, which have a high risk of malignant transformation or may even already represent pancreatic cancer at the time of diagnosis.

Benign pancreatic hyperenzymemia in children

One of us recently described chronic pancreatic hyperenzymemia in the absence of pancreatic or other disease in adult subjects. The aim of the present study was to describe this form of pancreatic hyperenzymemia in children. The study involved 15 children with this condition seen from September 1996 to December 2004. After initial evaluation, each child was seen by us once annually until the end of the study. Each check-up included serum amylase (normal values 20-220 IU/L), pancreatic isoamylase (17-115 IU/L) and lipase (24-270 IU/L) determinations as well as abdominal ultrasound. In six children, fecal elastase was also determined. At the initial assessment, 13 of the 15 children had abnormal serum increases in all three enzymes, one showed an increase only in lipase, and in the remaining child all three enzymes were present in normal concentrations. These latter two children had had abnormally elevated levels of all enzymes at the examination performed before this study began. During follow-up, enzyme concentrations remained abnormally elevated, although with wide fluctuations and transient normalizations. Considering the highest values of enzymes found in the various examinations performed during this study, the increase over the upper normal limit was in the range of 1.5- to 5.2-fold for amylase, 2.2-to 8.0-fold for pancreatic isoamylase, and 2.0- to 15.4-fold for lipase. Fecal elastase was normal in the six children in whom it was measured. No child had evidence of pancreatic or other disease, either at initial evaluation or during follow-up. The results of this study describe benign pancreatic hyperenzymemia in children. Although it is a benign condition, awareness of it is important to avoid unnecessary concern and multiple diagnostic procedures.

[Arginase activity in blood serum of patients with acute and chronic pancreatitis]

Pancreatitis is the most common disease of the pancreas. Difficulties in early recognition of pancreatitic diseases, particularly chronic pancreatitis, are the reason of the search for new diagnostic methods. In our earlier studies we have shown that the determination of arginase activity in serum of patients with pancreatic cancer may be useful test in preoperative diagnosis of this cancer. The aim of this study was to asses the arginase activity in serum of patients with acute and chronic pancreatitis before and after medical treatment.

MATERIAL AND METHODS

Arginase activity was studied in serum of 10 patients with acute and 10 patients with chronic pancreatitis obtained before, after and/or during the medical treatment.

RESULTS

The increase of arginase activity was observed in both studied groups before the medical treatment, and a statistically significant decrease after the treatment (p < 0,05). There were not significant differences between arginase activity in acute and chronic pancreatitis.

CONCLUSION

Arginase activity determination seems to be useful in monitoring the treatment of patients with acute and chronic pancreatitis.

Can pancreatic steatosis explain the finding of pancreatic hyperenzymemia in subjects with dyslipidemia?

OBJECTIVE

It has been proposed by some investigators that benign pancreatic hyperenzymemia could result from pancreatic steatosis that they believe would have been caused by dyslipidemia; their diagnosis of steatosis was based on the finding of a hyperechogenic pancreas at ultrasound. The aim of this study was to assess the validity of this proposed model.

METHODS

The study group was composed of 18 subjects with benign pancreatic hyperenzymemia, 12 men and 6 women; mean age, 55 years; range, 38 to 68 years. All 18 had dyslipidemia and 9 had hyperechogenic pancreas at ultrasound. In addition, 6 subjects with benign pancreatic hyperenzymemia but who did not have dyslipidemia or hyperechogenic pancreas and 10 healthy subjects with none of these conditions were also studied as controls. In each of these subjects, magnetic resonance imaging of the pancreas was performed to assess the presence of pancreatic steatosis.

RESULTS

Magnetic resonance imaging showed normal pancreas with no signs of fatty infiltration in all 18 subjects with dyslipidemia, including those with both dyslipidemia and hyperechogenic pancreas at ultrasound. A similar result was found in all control subjects.

CONCLUSION

The finding of a completely normal pancreas at magnetic resonance imaging does not support the proposed model in which pancreatic hyperenzymemia in subjects with dyslipidemia is attributed to pancreatic steatosis.

Polymorphisms of UDP-glucuronosyltransferase 1A7 are not involved in pancreatic diseases

BACKGROUND

Xenobiotic mediated cellular injury is thought to play a major role in the pathogenesis of pancreatic diseases. Genetic variations that reduce the expression or activity of detoxifying phase II biotransformation enzymes such as the UDP-glucuronosyltransferases might be important in this respect. Recently, a UGT1A7 low detoxification activity allele, UGT1A7*3, has been linked to pancreatic cancer and alcoholic chronic pancreatitis.

OBJECTIVE

To investigate whether UGT1A7 polymorphisms contribute to the risk of pancreatitis and pancreatic cancer.

METHODS

Genetic polymorphisms in the UGT1A7 gene were assessed in a large cohort of patients with different types of pancreatitis and pancreatic cancer originating from the Czech Republic (n = 93), Germany (n = 638), Netherlands (n = 136), and Switzerland (n = 106), and in healthy (n = 1409) and alcoholic (n = 123) controls from the same populations. Polymorphisms were determined by melting curve analysis using fluorescence resonance energy transfer probes. In addition, 229 Dutch subjects were analysed by restriction fragment length polymorphism.

RESULTS

The frequencies of UGT1A7 genotypes did not differ between patients with acute or chronic pancreatitis or pancreatic adenocarcinoma and alcoholic and healthy controls.

CONCLUSIONS

The data suggest that, in contrast to earlier studies, UGT1A7 polymorphisms do not predispose patients to the development of pancreatic cancer and pancreatitis.

Identification of pancreatic exocrinopathy in non-obese diabetic mice by gene subtraction analysis

Type 1 diabetes is an immune-mediated disease with pancreatic infiltration and subsequent beta cell destruction. In this study pancreatic exocrinopathy in non-obese diabetic mice (NOD) was identified using gene subtraction methods (SSH) and macroarray analysis. Female NOD mice were treated with cyclophosphamide for acceleration and synchronization of the disease process at 70 d of age and analysed 10 d later, before the onset of overt diabetes. Extraction of total RNA of pancreas was followed by subtraction using the SSH technique. Pools of cDNA were generated using total RNA from treated and untreated NOD mice. Subtraction of cDNA pools of cyclophosphamide treated mice from cDNA pools of untreated mice resulted in a cDNA library, from which 480 clones were randomly selected. The clones were hybridized against labelled cDNA-probes generated from cyclophosphamide-treated and control NOD mice. Fifty-three clones (11 %) revealed at least twofold differential gene expression after cyclophosphamide treatment. Three of the downregulated genes (amylase, carboxypeptidase and preprotrypsin) were selected for evaluation of macroarray data by quantitative real-time PCR. Analysis of real-time PCR data confirmed suppression of gene expression with highest fold change for amylase (4.68-fold) followed by carboxypeptidase (2.79-fold) and preprotrypsin (2.14-fold). These results lead to the conclusion that inflammation in this animal model of type 1 diabetes is not restricted to pancreatic islets and that subtraction followed by macroarray analysis is capable of identifying genes responsible associated with disease progression.

Human anionic trypsinogen: properties of autocatalytic activation and degradation and implications in pancreatic diseases

Human pancreatic secretions contain two major trypsinogen isoforms, cationic and anionic trypsinogen, normally at a ratio of 2 : 1. Pancreatitis, pancreatic cancer and chronic alcoholism lead to a characteristic reversal of the isoform ratio, and anionic trypsinogen becomes the predominant zymogen secreted. To understand the biochemical consequences of these alterations, we recombinantly expressed and purified both human trypsinogens and documented characteristics of autoactivation, autocatalytic degradation and Ca2+-dependence. Even though the two trypsinogens are approximately 90% identical in their primary structure, we found that human anionic trypsinogen and trypsin exhibited a significantly increased (10-20-fold) propensity for autocatalytic degradation, relative to cationic trypsinogen and trypsin. Furthermore, in contrast to the characteristic stimulation of the cationic proenzyme, acidic pH inhibited autoactivation of anionic trypsinogen. In mixtures of cationic and anionic trypsinogen, an increase in the proportion of the anionic proenzyme had no significant effect on the levels of trypsin generated by autoactivation or by enterokinase at pH 8.0 in 1 mm Ca2+- conditions that were characteristic of the pancreatic juice. In contrast, rates of trypsinogen activation were markedly reduced with increasing ratios of anionic trypsinogen under conditions that were typical of potential sites of pathological intra-acinar trypsinogen activation. Thus, at low Ca2+ concentrations at pH 8.0, selective degradation of anionic trypsinogen and trypsin caused diminished trypsin production; while at pH 5.0, inhibition of anionic trypsinogen activation resulted in lower trypsin yields. Taken together, the observations indicate that up-regulation of anionic trypsinogen in pancreatic diseases does not affect physiological trypsinogen activation, but significantly limits trypsin generation under potential pathological conditions.

Immunohistochemical analysis of cyclooxygenase-2 and vascular endothelial growth factor in pancreaticobiliary maljunction

Recent studies have elucidated that cyclooxygenase (COX)-2 is strongly related to cancer progression or development by means of its anti-apoptotic effect, enhancement of angiogenesis or decrease of cell-to-cell adhesive activity. However, there is no report on the relationship between COX-2 expression and angiogenesis in pancreaticobiliary maljunction (PBM). We examined the correlation between the overexpression of COX-2 and vascular endothelial growth factor (VEGF) in 65 lesions from 30 patients with PBM immunohistochemically. The positive expression of COX-2 was found in 20% of regenerative epithelium, 11.1% of hyperplasia without atypia, 86.4% of hyperplasia with mild atypia, 75% of dysplasia, and 75% of cancerous lesions. VEGF was highly expressed in 80% of regenerative epithelium, 27.8% of hyperplasia without atypia, 86.4% of hyperplasia with mild atypia, 66.7% of dysplasia, and 75% of cancerous lesions. The positive rate of both COX-2 and VEFG expression was significantly higher in hyperplasia with atypia, dysplasia and cancerous lesions than that in hyperplasia without atypia. In addition, there was a statistically significant correlation between COX-2 and VEGF overexpression among all lesions. In 6 of 8 patients of various histological types, both COX-2 and VEGF were stained in almost exactly the same locations. In addition, there were no significant differences between the degree of inflammatory cell infiltration in the surrounding stroma and the expression of COX-2 and VEGF, respectively. These results demonstrated a strong relationship between COX-2 and VEGF overexpression in PBM. Therefore, chemoprevention via the suppression of angiogenesis by means of COX-2 inhibitor may be effective in PBM.

[Rhabdomyolysis following cerivastatin monotherapy--implications for therapy with HMG-CoA reductase inhibitors]

Cerivastatine was administered as a reversible HMG-CoA reductase inhibitor (statine) to treat hypercholesterolemia until its withdrawal from the market following 52 reports of death due to drug-related rhabdomyolysis and acute renal failure. In most cases, cerivastatine was applied in combination with drugs which influenced the liver metabolism of cerivastatine via cytochromeoxidase P 450 isoenzymes. We report a well-documented case of acute rhabdomyolysis following cerivastatine monotherapy. The diagnosis was confirmed additionally by muscle biopsy.Finally,we give an overview of the current knowledge concerning therapy with HMG-CoA reductase inhibitors,1 year after the withdrawal of cerivastatine from the market.

Pancreatic injury in equine acute abdomen evaluated by plasma trypsin activity and histopathology of pancreatic tissue

In cases of equine acute abdominal disease, where pancreatic damage is suspected, pancreatic damage can be assessed by measuring increased trypsin activity in the plasma of horses suffering intestinal obstruction and severe shock. The pancreas is particularly vulnerable to splanchnic hypoperfusion because it is a highly active tissue. In this study, 10 horses undergoing abdominal surgery for intestinal obstruction were assayed for trypsin activity on admission and, because of extensive intestinal lesions that were not amenable to surgery, euthanasia was selected; the pancreas was removed before euthanasia. Trypsin activity in the plasma of these horses was significantly higher than in healthy horses (196 ng/ml +/- 128.2 versus 28.5 ng/ml +/- 19.2; P = 0.0026). Light and transmission electron microscopy revealed slight to severe lesions of vacuolar degeneration, a few zymogen granules, dilation of the endoplasmic reticulum, and swelling of mitochondria in the exocrine pancreas. The activation of an inflammatory cascade occurring during strangulating intestinal obstruction could increase pancreatic anoxic lesions caused by severe shock and hypoperfusion in the horse. Further studies will show the significance of pancreatic lesions and the ensuing damage in equine acute intestinal obstruction and shock.

Vanishing bile duct syndrome associated with elevated pancreatic enzymes after short-term administration of amoxicillin

Amoxicillin is a widely used antibiotic, rarely being considered a cause of hepatic injury. We report the case of a 45-year-old woman who developed a vanishing bile duct syndrome 8 weeks after initiation of amoxicillin therapy. Liver biopsy showed destruction and loss of preformed bile ducts together with an inflammatory infiltrate involving eosinophilic leucocytes. Cholestasis was progressive despite prednisolone treatment and was accompanied by elevation of pancreatic enzymes. The patient died after 18 months from progressive liver failure. This case illustrates that amoxicillin alone can be a cause of progressive and ultimately fatal vanishing bile duct syndrome.

Serum levels of procarboxypeptidase B and its activation peptide in patients with acute pancreatitis and non-pancreatic diseases

BACKGROUND

Carboxypeptidase B from the pancreatic gland may exist in three different molecular and immunoreactive forms: the proenzyme, the active enzyme, and the activation peptide.

AIMS

To investigate levels of procarboxypeptidase B (proCAPB) and its activation peptide in serum in acute pancreatitis to test the accuracy of these two variables as markers for the diagnosis of acute pancreatitis and for prediction of pancreatic necrosis. To elucidate whether leakage of proenzymes and activation of proenzymes reflect two different pathophysiological events in acute pancreatitis.

METHODS

Sera from patients with acute pancreatitis (n=85) and acute abdominal pain of non-pancreatic origin (n=53) were analysed for proCAPB and its activation peptide. Patients with pancreatitis were divided into necrotising (n=33) and oedematous attacks (n=52) using contrast enhanced computed tomography. Accuracy was determined using receiver operating characteristic curve analysis.

RESULTS

Immunoreactive carboxypeptidase B activation peptide (ir-CAPAP) concentration in serum on admission was 0.7 nmol/l (0-18.1) in patients with oedematous pancreatitis compared with 5.8 nmol/l (1.9-34) in patients with later development of pancreatic necrosis. Elevated levels of the activation peptide on admission correlated with an accuracy of 92% to later development of pancreatic necrosis. Ir-proCAPB concentration in serum on admission was 16.0 nmol/l (1.4-50.5) in all patients with acute pancreatitis versus 0.3 nmol/l (0-3.6) in patients with non-pancreatic acute abdominal disorders. Cases with oedematous pancreatitis had ir-proCAPB levels of 15.4 nmol/l (1.4-50.5) versus 19.1 nmol/l (2.7-36.1) in cases with later development of pancreatic necrosis. Measurement of the proenzyme can thus be useful for the diagnosis of acute pancreatitis (accuracy 99%) but levels did not correlate with later development of pancreatic necrosis (accuracy 56%).

CONCLUSION

Leakage of proenzymes occurs in acute pancreatitis, irrespective of severity, while development of pancreatic necrosis occurs only when there is activation of the proenzymes.

Recommendations for the routine use of pancreatic amylase measurement instead of total amylase for the diagnosis and monitoring of pancreatic pathology

This document reviews the scientific evidence expected to persuade clinical laboratories to substitute pancreatic amylase measurement for total amylase in cases of suspected pancreatic pathology. A substantial evidence is now available to support such change. The measurement of pancreatic amylase in serum is: 1. more sensitive and specific for the detection of pancreatic tissue damage than that of the total enzyme activity, 2. easy and quick to perform in emergency conditions, 3. analytically precise in relation to its clinical application, 4. suitable for easy transfer and comparison of results from different care delivery units, and 5. characterized by well-defined decision limits for the diagnosis of acute pancreatitis.

Pancreatic hyperamylasemia during acute gastroenteritis: incidence and clinical relevance

BACKGROUND

Many case reports of acute pancreatitis have been reported but, up to now, pancreatic abnormalities during acute gastroenteritis have not been studied prospectively.

OBJECTIVES

To evaluate the incidence and the clinical significance of hyperamylasemia in 507 consecutive adult patients with acute gastroenteritis.

METHODS

The clinical significance of hyperamylasemia, related predisposing factors and severity of gastroenteritis were assessed.

RESULTS

Hyperamylasemia was detected in 10.2 % of patients studied. Although amylasemia was found over four times the normal values in three cases, the clinical features of acute pancreatitis were recorded in only one case (0.1%). Hyperamylasemia was more likely (17%) where a microorganism could be identified in the stools (p < 0.01). Among patients with positive stool samples, Salmonella spp. and in particular S. enteritidis, was the microorganism most frequently associated with hyperamylasemia [17/84 (20.2 %) and 10/45 (22.2%), respectively], followed by Rotavirus, Clostridium difficile and Campylobacter spp. Patients with hyperamylasemia had more severe gastroenteritis with an increased incidence of fever (80 % vs 50.6 %, O.R. 3.0; P < 0.01), dehydration (18% vs 8.5%; O.R. 2.5; P < 0.05), and a higher mean number of evacuations per day (9.2 vs 7.5; P < 0.05) than those with amylasemia in the normal range. Hyperamylasemia was significantly associated with cholelithiasis, (30.0 % vs 10.7%, O.R. 3.5; P < 0.01) and chronic gastritis or duodenal ulceration (22.0 % vs 10.2%, O.R. 2.4, P < 0.05).

CONCLUSIONS

Hyperamylasemia is relatively frequent, and is associated with severe gastroenteritis. However, acute pancreatitis in the setting of acute gastroenteritis, is a rare event.

Risk factors for acquisition of hepatitis C virus infection: a case series and potential implications for disease surveillance

BACKGROUND

Transmission of hepatitis C virus (HCV) is strongly associated with use of contaminated blood products and injection drugs. Other "non-parental" modes of transmission including sexual activity have been increasingly recognized. We examined risk factors for acquiring HCV in patients who were referred to two tertiary care centers and enrolled in an antiviral therapy protocol.

METHODS

Interviews of 148 patients were conducted apart from their physician evaluation using a structured questionnaire covering demographics and risk factors for HCV acquisition.

RESULTS

Risk factors (blood products, injection/intranasal drugs, razor blades/ toothbrushes, body/ear piercing, occupational exposure, sexual activity) were identified in 141 (95.3%) of participants; 23 (15.5%) had one (most frequently blood or drug exposure), 41 (27.7%) had two, and 84 (53.4%) had more than two risk factors. No patient reported sexual activity as a sole risk factor. Body piercing accounted for a high number of exposures in women. Men were more likely to have exposure to street drugs but less exposure to blood products than women. Blood product exposure was less common in younger than older HCV patients.

CONCLUSION

One and often multiple risk factors could be identified in nearly all HCV-infected patients seen in a referral practice. None named sexual transmission as the sole risk factor. The development of a more complete profile of factors contributing to transmission of HCV infection may assist in clinical and preventive efforts. The recognition of the potential presence of multiple risk factors may have important implications in the approach to HCV surveillance, and particularly the use of hierarchical algorithms in the study of risk factors.

Involvement of inducible isoforms of COX and NOS in streptozotocin-pancreatic damage in the rat: interactions between nitridergic and prostanoid pathway

Streptozotocin-induced pancreatic damage involves nitric oxide (NO) and prostaglandins (PGs) overproduction. In this work we aim to evaluate a putative relationship between the elevated NO levels and the altered prostanoid production in pancreatic tissue from streptozotocin-diabetic rats. Total NOS activity and nitrate/nitrite pancreatic levels in tissues from diabetic rats are decreased when the cyclooxygenase (COX) inhibitor indomethacin (INDO) is added to the incubating medium, while the addition of PGE(2)increases nitrate/nitrite production and NOS levels. INDO and PGE(2)selectively affect Ca(2+)-dependent NOS (iNOS) activity in diabetic tissues, and they have not been able to modify nitrate/nitrite levels, iNOS or Ca(2+)-dependent (cNOS) in control tissues. When the NOS inhibitor L-NMMA was present in the incubating medium, control pancreatic [(14)C]-Arachidonic Acid ([(14)C]-AA) conversion to 6-keto PGF(1 alpha)and to TXB(2)was lower, and PGF(2 alpha), PGE(2)and TXB(2)production from diabetic tissues diminished. The NO donors, spermine nonoate (SN) and SIN-1, enhanced TXB(2)levels in control tissues, while PGF(2 alpha), PGE(2)and TXB(2)levels from diabetic tissues were increased. PGE(2)production from control and diabetic tissues was assessed in the presence of the NO donor SN plus INDO or NS398, a specific PG synthase 2 inhibitor. When SN combined with INDO or NS398 was added, the increment of PGE(2)production was abolished by both inhibitors in equal amounts, indicating that the activating effect of nitric oxide is exerted on the inducible isoform of cyclooxygenase. In the diabetic rat, prostaglandins and NO seem to stimulate the generation of each other, suggesting a lack of regulatory mechanisms that control the levels of vasoactive substances in acute phase of beta-cell destruction.

Pancreatic necrosis in New World camelids: 11 cases (1990-1998)

OBJECTIVE

To determine clinical, clinicopathologic, and postmortem abnormalities in New World camelids with pancreatic necrosis.

DESIGN

Retrospective study.

ANIMALS

10 llamas and 1 alpaca.

PROCEDURES

Medical records of animals in which a diagnosis of pancreatic necrosis had been made on the basis of histologic examination of necropsy specimens or on the basis of clinical signs and results of clinicopathologic testing were reviewed.

RESULTS

The initial owner complaint varied, and various other conditions were diagnosed. Clinical and clinicopathologic abnormalities were vague. Amylase activity was higher in abdominal fluid than in serum in 5 of 7 animals, and lipase activity was higher in abdominal fluid than in serum in all 7. Four animals survived, and 7 died or were euthanatized. Only 1 of the animals that died had marked inflammation of the pancreatic parenchyma. All 7 had necrosis and saponification of fat in and surrounding the pancreas.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that pancreatic necrosis may develop in New World camelids, but clinical signs are vague, and the condition may easily be confused with other diseases. The only laboratory test that appeared to be helpful in the antemortem diagnosis of pancreatic necrosis was comparison of amylase and lipase activities in abdominal fluid and serum.

Proteases in the evaluation of pancreatic function and pancreatic disease

This paper reviews the role of pancreatic proteases (focusing upon trypsin, chymotrypsin and elastase) in the diagnosis and management of chronic pancreatic insufficiency (CPI), emphasizing advances over the last 5 years. Some important novel aspects of these enzymes in acute pancreatitis are also described, including their role in diagnosis and their interaction with cholecystokinin in the pathogenesis of the disease. The recent interest in these enzymes as agents promoting the spread of cancer in animals and human subjects is also described. A hierarchical approach has been taken to explore the advantages and limitations of tests in different source materials: serum, feces, duodenal aspirate, and non-invasive pancreatic function tests. The practical usefulness of fecal elastase-1 and of fecal chymotrypsin concentrations in diagnosis and management of CPI, respectively, is one of the major lessons to be learned from analysis of the recent literature, and forms the principal message of this review.

13C-egg white breath test: a non-invasive test of pancreatic trypsin activity in the small intestine

BACKGROUND

The recent availability of egg white protein highly enriched with (13)C has allowed breath test technology to be adapted for the study of protein digestion and absorption. Pancreatic trypsin is considered to be the key enzyme in the proteolytic cascade.

AIM

To evaluate trypsin activity in the small intestine of healthy volunteers and patients with pancreatic disease by a recently developed (13)C-egg white breath test.

METHODS

A total of 48 healthy volunteers and 30 patients with pancreatic disease were studied after ingestion of a test meal consisting of 22 g (13)C-labelled egg protein. Breath samples were taken before and after ingestion of the meal and analysed for (13)CO(2) concentration. Moreover, pancreatic trypsin output after maximal stimulation was measured in 13 patients and nine healthy volunteers.

RESULTS

The six hour cumulative (13)CO(2) excretion in breath was significantly lower in patients than controls (mean (SEM): 6.23 (0.82)% v 19.16 (0. 58)%, p<0.0001). An excellent correlation was found between the six hour cumulative (13)CO(2) excretion and trypsin activity after maximal pancreatic stimulation.

CONCLUSION

The non-invasive (13)C-egg white breath test is promising as an indirect pancreatic proteolytic function test.

[Determination and clinical relevance of fecal pancreatic elastase in dogs]

The determination of faecal pancreatic elastase 1 is a reliable test for the diagnosis of chronic pancreatic diseases in man due to its high sensitivity and specificity (93%). A clinical study was performed to investigate the detectability of canine faecal pancreatic elastase with polyclonal anti human pancreatic elastase 1 antibodies in 52 dogs with chronic diarrhoea and weight loss. To assess the diagnostic value of this parameter for the diagnosis of exocrine pancreatic insufficiency (EPI) in dogs faecal chymotrypsin activity was determined and serum trypsin-like immunoreactivity (TLI) concentration was measured within the Ceruletid test in all patients. The study revealed that canine faecal pancreatic elastase cross reacts with polyclonal anti human pancreatic elastase 1 antibodies. In comparison with the results of the other pancreas tests it was proved that the concentration of canine faecal pancreatic elastase determined by rocket immunoelectrophoresis is highly sensitive for EPI in dogs (sensitivity 100%) but there are species differences in specificity between man and dog (specificity 56.5%).

[Chronic pleural effusion from the pancreas]

Chronic, pleural effusion, characterized by a very high pancreatic enzymes activity is a rare complication of the pancreatic diseases. It is pathognomonic for the pancreaticopleural fistula, arising most frequently in the patients with chronic, alcoholic pancreatitis. Clinical manifestations of the chronic pleural effusion lead the physician's attention to the pulmonary diseases, what often is the cause of misdiagnosis. The diagnostics of this pancreatic diseases complication bases on the effusion's pancreatic enzymes activity evaluation and visual methods such as computed tomography, ultrasonography, endoscopic retrograde cholangiopancreatography. Management can be started conservatively, but if the result is not adequate, surgical treatment is needed. As the cases of pancreatic, chronic pleural effusion may be commoner than it is reported, author postulates a routine evaluation of the pleural effusion alpha-amylase activity in each case of the unclear pleural effusion.

Biochemical assessment of pancreatic disease in human immunodeficiency virus infected men

AIM

To determine the usefulness of measuring amylase activity as an indicator of pancreatic disease in human immunodeficiency virus (HIV) positive patients.

METHODS

A prospective study of 129 ambulant HIV positive males. Total amylase, pancreatic amylase, and lipase activities were assayed using commercial test kits on an automated analyser. Samples with raised amylase were examined for the presence of macroamylasaemia using cellulose acetate electrophoresis.

RESULTS

Thirty six (28%) of the subjects had raised total amylase activities compared with healthy, age matched blood donors. However, almost half of these were because of an increase of the salivary fraction. Four subjects were found to have macroamylasaemia. Pancreatic amylase and lipase assays, more specific indicators of pancreatic disease, produced significantly fewer abnormal results. There was no association between abdominal symptoms and elevated enzyme levels.

CONCLUSIONS

Total amylase is a poor indicator of pancreatic disease in HIV infected outpatients. Specific assays for pancreatic amylase offer advantages over the traditional total amylase assay. The lipase assay produced the least number of abnormal results and its use could improve the biochemical identification of patients with possible pancreatic disease and allow a more selective investigation of these cases.

Hepatobiliary and coexisting pancreatic duct abnormalities in patients with inflammatory bowel disease

BACKGROUND

We performed a cross-sectional study to evaluate the prevalence of hepatobiliary disease in unselected patients with inflammatory bowel disease (IBD), to estimate the frequency of coexisting cholangiographic and pancreatographic duct abnormalities, and to correlate the findings with clinical, endoscopic, and histologic variables.

METHODS

We screened 237 IBD patients for increased liver function values. Further, hepatobiliary evaluation consisted of transabdominal ultrasonography, endoscopic retrograde cholangiopancreatography (ERCP), and a liver biopsy. In addition, we evaluated the ERCP findings of patients with abnormal pancreatic screening tests (pancreatic enzymes or para-aminobenzoic acid excretion).

RESULTS

Laboratory signs of hepatobiliary disease were found in 37 (16%) of our IBD patients. Abnormal liver test results were commoner in patients with Crohn's disease (CD) than in patients with ulcerative colitis (UC) (30.4% versus 11.2%, P < 0.05), and a similar trend was observed in the frequency of primary sclerosing cholangitis (PSC) in the respective groups of IBD patients. When the ERCP findings were combined with liver histology, 26 (11% of the whole study group) patients with PSC were found, with small-duct disease included. In 23 (10% of the whole study group) patients, definite cholangiographic changes consistent with PSC were found. Eleven (48%) of these showed coexisting pancreatic duct abnormalities. The prevalence of coexisting cholangiographic and pancreatographic duct changes in the whole study group was 4.6%.

CONCLUSION

Hepatobiliary disease is at least equally common in patients with UC and CD. Coexisting cholangiographic and pancreatographic duct abnormalities in patients with IBD are relatively frequent and are considered extraintestinal manifestations of IBD.

Expression of cathepsin E in pancreas: a possible tumor marker for pancreas, a preliminary report

Ductal cancers of the pancreas frequently express markers of gastrointestinal epithelial cells. Cathepsin E (CTSE) is a non-secretory, intracellular, but non-lysosomal proteinase found in the highest concentration in the superficial epithelial cells of the stomach. The aims of our study were to examine the expression of CTSE in the pancreas, to establish an assay system of CTSE and to evaluate the diagnostic usefulness of CTSE in the pancreatic juice. Eleven patients with pancreatic ductal adenocarcinoma, 10 with mucin-producing adenoma, 3 with intraductal papillary hyperplasia and 43 with chronic pancreatitis were examined. Surgically resected pancreatic tissues were subjected to immunohistochemistry for CTSE. Pancreatic juice was collected from the patients and subjected to sandwich ELISA and Western analysis for detecting CTSE. Positive staining for CTSE was observed in pancreatic ductal adenocarcinoma by immunohistochemistry. CTSE was also expressed in mucin-producing adenoma, intraductal papillary hyperplasia and mucinous hyperplasia. CTSE in the pancreatic juice was present in 8 of 11 patients with pancreatic ductal adenocarcinoma, 5 of 10 patients with mucin-producing tumor, 1 of 3 patients with intraductal papillary hyperplasia and 4 of 43 patients with chronic pancreatitis. The detection frequency of CTSE in the pancreatic juice was significantly higher in the patients with pancreatic ductal adenocarcinoma than in the patients with chronic pancreatitis. Our findings suggest that the expression of CTSE is associated with the pathogenesis of pancreatic ductal adenocarcinoma, that CTSE in the pancreatic juice seems to be a useful marker for a definitive diagnosis and that CTSE may be expressed at a relatively early stage of multistep carcinogenesis in pancreatic lesions.

In vivo interference of heparin bolus injection with photometric continuous lipase determination

The new photometric lipase determinations use diacylglycerols as substrates in a micellar solution, whereas the turbidimetric method is based on emulsified triacylglycerols degradation. Extrahepatic lipoprotein lipase, which is well known to be liberated by heparin from the capillar binding sites, may cleave triacylglycerols as well as diacylglycerols. When a heparin bolus injection is given to a patient, the released lipoprotein lipase renders high lipase activities in blood misleading for a pancreatic disorder.

Evaluation of ERCP- and endoscopic sphincterotomy-induced pancreatic damage: a prospective study on the time course and the significance of serum levels of pancreatic secretory enzymes

In the present study the time courses of serum lipase, serum amylase and serum elastase 1 after ERCP/ES as indicators for pancreatic damage were prospectively analysed in 46 cases. The elevations of pancreatic enzymes after ERCP/ES scattered in a wide range and elevations occured which were greater than one hundred times the upper limit of normal. A moderate increment was seen as early as 5 minutes after intubation of the papilla. Elevations above the upper limit of normal were still seen at 24 hours after the procedure. The maxima occurred about 6 hours after the procedure. Lipase was the most sensitive among the parameters tested, nearly 50% of the cases with previously normal values revealed elevated lipase after the procedure. For daily clinical routine a single lipase measurement at 2 hours after the beginning of the ERCP/ES provides valuable information for planning further surveillance. Younger age and high calcium levels seem to be risk factors for ERCP/ES-induced pancreatic damage. The time course of serum lipase seems to be a more reliable criterion for ERCP/ES-induced pancreatic damage than the poorly defined complication of post-ERCP pancreatitis . The high incidence of a measurable pancreatic injury after ERCP/ES provides a sensitive tool for the testing of drugs claimed to be protective for the pancreas and for evaluating new ERCP/ES techniques. Measurement of the serum lipase before, 8 and 24 hours after the procedure, and a detailed description of degree and duration of pain, are necessary for such studies.