Amylase activity of parotid saliva in acute and chronic pancreatitis

The activity of the alpha-amylase was estimated in the parotid resting saliva of 17 subjects without evidence of pancreatic disease, 17 patients with chronic relapsing pancreatitis in the intervals between acute attacks, and also in 4 patients with acute pancreatitis and 3 patients with an acute attack of chronic relapsing pancreatitis. In the patients with chronic relapsing pancreatitis between attacks the concentration, output and specific activity of the salivary amylase were significantly lowered. The patients with acute pancreatitis exhibited salivary amylase concentrations in the uppper normal to grossly supranormal range, whereas those of the patients with acute attacks of chronic relapsing pancreatitis were distinctly reduced. Unlike the amylase output, the amylase concentration was independent of the rate of salivary flow. Simultaneous infusion of secretin and pancreozymin produced a significant increase in the parotid salivary amylase levels in both the patients without pancreatic disease and in those with chronic relapsing pancreatitis between acute attacks.     

Clinical effects of anticancer drugs to pancreatic diseases as protein synthesis inhibitors

The anticancer drugs, like 5-Fluorouracil, which are believed to interfere with enzyme protein synthesis in the exocrine cells of pancreas were administered intravenously to fifteen patients with various pancreatic diseases. The improvement of clinical symptoms and the diminution of serum and urinary amylase levels were observed in four cases with acute pancreatitis and two cases with chronic relapsing pancreatitis. The postoperative complications, namely the formation of pancreatic fistula and the rupture of pancreaticojejunostomy, or the aggravation of concomitant pancreatitis were not observed in three cases with benign surgical pancreatic diseases and six cases with pancreatic carcinoma. Furthermore, the diminution of amylase and protein output of pancreatic juice from canulae inserted into pancreatic ducts were observed.     

Serum amylase isozyme changes in chronic pancreatitis and their clinical significance

The diagnostic usefulness of serum amylase isozyme measurement was investigated in 17 cases of definite chronic pancreatitis and 13 cases of suspected chronic pancreatitis, a total of 30 cases. Six types of serum isoamylase patterns were distinguished according to the character of the two main amylase activities at the fraction of fast-gamma globulin and pre-gamma globulin. The amylase activity of the fast-gamma fraction rises in acute exacerbation, and falls in cases of chronic calcifying pancreatitis and in cases with a marked decrease in pancreatic exocrine function. Especially, a fall in fast-gamma amylase activity excellently reflects a decrease in pancreatic enzyme production. The measurement of amylase activity at the fast-gamma fraction therefore appears to be a useful method for assessing pancreatic damage. The significance of a frequent rise in pre-gamma amylase activity in chronic pancreatitis remains unknown.     

Comparison of the effects of natural and synthetic secretin on the exocrine secretion of the human pancreas (author's transl)

In 16 healthy male subjects the effects of natural and synthetic secretin on the function of the exocrine pancreas were compared. Following; stimulation with secretin in all cases pancreozymin was injected to ascertain normal pancreatic secretory capacity. The methods applied corresponded to those used in the multicenter study of the European Pancreatic Club. No significant differences were found between the results concerning volume of secretion, maximal bicarbonate concentration, maximal bicarbonate output and enzyme secretion rates after stimulation with natural and synthetic secretin, respectively. It is concluded that the synthetic peptide can be utilized in the same way as the natural product in the secretin-pancreozymin-test.     

The behavior of mucopolysaccharide in the pancreatic juice in chronic pancreatitis

In order to study whether or not mucosubstance increases occur in the pancreatic juice of patients with chronic pancreatitis, hexosamine was measured in duodenal aspirates during the secretin phase (S-40) following pancreozymin-secretin stimulation in 16 normal subjects, 37 patients with chronic pancreatitis, 6 patients with alcoholism, 13 patients with gallstones, and 11 patients with peptic ulcer. The hexosamine concentrations in the pancreatic secretions showed a negative correlation with the bicarbonate concentrations and volume output. Rises in hexosamine concentration were seen in alcoholism and chronic pancreatitis, especially in alcoholic pancreatitis. This is probably intimately related with the repeated ingestion of large amounts of alcohol over long periods of time. Since high hexosamine values are noted in the relapsing type of chronic alcoholic pancreatitis, increases in viscosity due to mucosubstance increases in the pancreatic juice are probably related with the recurrence of acute attacks accompanying ductal stenosis or obstruction.     

A method to measure arbitrary k-space trajectories for rapid MR imaging

We assessed the clinical usefulness of the intraductal secretin test in order to ascertain whether it can substitute for the conventional duodenal secretin test. Duodenal juice was obtained with a triple-lumen tube and pure pancreatic juice was obtained by retrograde cannulation of the main pancreatic duct using a duodenofiberscope. Pancreatic secretion was stimulated by a bolus intravenous injection of secretin (100 units). The two tests showed comparable interindividual coefficients of variation, significantly good correlations, and comparable diagnostic efficiencies. The intraductal secretin test showed no less reproducibility than that of the duodenal secretin test as reported in the literature. In the intraductal secretin test, secretory volume, peak flow rate, bicarbonate output, and lipase output yielded the best diagnostic efficiency, followed by amylase output and maximal bicarbonate concentration. In the intraductal secretin test, a 10-min collection provided as much information as a 20-min collection. We conclude, therefore, that the 10-min intraductal secretin test is as useful as the conventional duodenal secretin test in assessing exocrine pancreatic function and that the most discriminatory parameters are secretory volume, bicarbonate output, and amylase (or lipase) output.     

Retrograde pancreatography. Technical tips and spectrum of pathology

ERP is an important technique in the diagnosis of diseases involving the pancreatic ducts, in determining therapeutic strategy, and in assessing the results of surgical bypass procedures. ERP facilitates the diagnosis of the majority of pancreatic tumors at a stage when they normally present to the clinician. It assists the diagnosis of small tumors in the ampullary region at an early stage when other tests are negative. In cases of obscure recurrent pancreatitis, ERP may identify a mechanical cause (e.g., stone, stricture). ERP is useful in the diagnosis of CCP only in the precalcified stage. If histologic confirmation already has been obtained at surgery, ERCP is not required. Compared with noninvasive techniques, ERP provides additional information: It enables a concomitant examination of the gastroduodenal tract and opacification of the bile ducts; additional procedures may be performed, such as intraductal cytologic brushings, biochemical and cytologic analysis of pancreatic juice, endoscopic manometry, and pancreatoscopy. The diagnostic yield is increased if these procedures are performed during ERCP. Because ERP outlines the ductal anatomy, it is of great value in assessing therapeutic strategy. In cases of acute recurrent pancreatitis or chronic pancreatitis, ERP provides an important baseline for performing procedures such as ductal drainage and therefore reduces the inappropriate use of exploratory laparotomy. In cases of necrotic pancreatitis or pancreatic trauma, ERP enables accurate localization of a pancreatic fistula and facilitates any subsequent surgical procedure. Finally, ERP is the method of choice when assessing the patency of pancreatic-digestive anastomosis.     

Health care enigmas

A study of the exacrinous function of the pancreas made in 205 healthy persons aged from 18 to 90 has evidenced that in ageing there takes place in the duodenal mixture of juices a statistically significant decline in the activity of trypsin and of its inhibitor, lipase, amylase, in the level of bicarbonates and in the volume of the juice along with an increase in the content of chlorides. In ageing more marked changes become apparent following application of the agents stimulating the pancreatic secretion of the secretin and pancreozymin mechanism of action, and then the greatest changes are seen to occur on the level of lipase and trypsin and the least -- on the level of the amylase activity and the bicarbonate alkalinity content. Note has also been taken of an age-specific statistically significant decline in the activity of the studied pancreatic enzymes in the blood (trypsin, its inhibitor, lipase, amylase) and in the urine (lipase, amylase).     

Plasma alpha 2-macroglobulin-trypsin complexlike substance (MTLS) in pancreatic disease

alpha 2-macroglobulin-trypsin complexlike substance (MTLS) was determined in plasma of pancreatic and nonpancreatic diseases using a two-step enzyme immunoassay to study the diagnostic and pathophysiological significance of MTLS. Plasma levels of MTLS in acute pancreatitis (mean +/- SD = 265.6 +/- 346.2 ng/ ml, n = 9), calcified chronic pancreatitis (128.6 +/- 257.4, n = 13), and noncalcified chronic pancreatitis (13.5 +/- 12.5, n = 10) were significantly higher than that in controls (3.6 +/- 1.8, n = 81). In other diseases such as gastric cancer, hepatoma, diabetes mellitus, and gallstones, MTLS values were not different from those of control. Plasma MTLS values showed low correlation with serum trypsin, elastase 1, pancreatic amylase, lipase, and pancreatic secretory trypsin inhibitor (PSTI). The elevation of plasma MTLS values in acute pancreatitis suggests that plasma MTLS levels reflect that protease is inappropriately activated in pancreatic acinar cell and released into the circulation and that the determination of MTLS can be useful for diagnosis and pathophysiology of acute pancreatitis and chronic pancreatitis.     

Simultaneous determinations of pancreatic phospholipase A2 and prophospholipase A2 in various pancreatic diseases

Pancreatic phospholipase A2 (PLA2) is secreted into the pancreatic juice by pancreatic acinar cells as a proenzyme (proPLA2), which is activated by trypsin. Radioimmunoassays with monoclonal antibodies to PLA2 and proPLA2 were used to examine the serum PLA2 and proPLA2 levels simultaneously in patients with various pancreatic diseases. In healthy subjects, proPLA2 proved to be the major form of the enzyme. The serum PLA2 level were found to be significantly increased in patients with acute pancreatitis, the active phase of chronic relapsing pancreatitis, and the early stage of pancreatic cancer. In the terminal stage of pancreatic cancer the serum PLA2 level became low. In patients with chronic pancreatitis, significant correlations were observed between the levels of factors evaluated by the secretin test and the serum total PLA2 and proPLA2 level, but not the PLA2 level. The serum PLA2 and proPLA2 concentrations, and the proportion of proPLA2 in the total, were within normal ranges in patients with liver cirrhosis, hepatocellular carcinoma, and chronic renal failure. These results suggest that simultaneous measurements of serum PLA2 and proPLA2 are clinically useful for diagnosis and monitoring of the active phase of pancreatitis.     

The two stage provocative test for pancreatic disease by serum enzyme measurements

The pancreas can be studied for obstructive disease by measuring serum lipase levels in the two stage provocative test. The test is nonspecific but noninvasive and applicable to all stages of pancreatic diseases. In this test, the pancreas is stimulated twice in two hour intervals before measuring the serum enzyme levels: first, with pancreozyin and secretin--the stage 1 test and, second, with pancreozymin, secretin, betazole hydrochloride and morphine sulfate--the stage 2 test. Among the pancreatic enzymes measured, lipase was most reliable. Serum lipase level elevation in the stage 1 test indicates a pancreatic abnormality and it completes the test. Patients who fail to respond to the stage 1 test have either a normal pancreas or pancreatic insufficiency and need the stage 2 test for differential diagnosis. In the stage 2 test, the serum lipase level is elevated in patients with a normal pancreas but not in those with pancreatic insufficiency. As a preliminary study, ten patients with carcinoma of the pancreas, two with pancreatitis and ten in the control group were studied. All patients with a known pancreatic disease demonstrated an abnormality in the test. Two of ten in the control group also had abnormal results. The two stage provocative test may be used prior to undertaking more invasive examinations, such as an arteriogram, in patients who are suspected of having pancreatic disease, yet other tests have failed to indicate it.     

Thoracoscopic surgery using voice controlled robot for spontaneous pneumothorax

Although there is abundant literature on the association of L-asparaginase and acute pancreatitis in patients undergoing chemotherapy, few studies have investigated the usefulness of pancreatic enzyme measurement in the early diagnosis of L-asparaginase-induced acute pancreatitis. We measured levels of serum pancreatic enzymes before, during, and after L-asparaginase therapy in nine children with acute lymphocytic leukaemia or non-Hodgkin lymphoma. Serum levels of amylase, pancreatic isoamylase, and lipase did not change between the 1st and 30th day of L-asparaginase administration. However, the serum trypsin and elastase- levels, 10 and 20 days after beginning L-asparaginase therapy, were significantly higher than those prior to therapy. CONCLUSION: L-asparaginase may induce subclinical pancreatitis and the estimation of serum trypsin and elastase-1 may be useful in the early diagnosis of L-asparaginase-induced acute pancreatitis.     

Multiple products of class Ib Qa-2 genes which ones are functional?

Magnetic resonance cholangiopancreatography (MRCP) is a diagnostic method that uses three-dimensional data sets for projection images, as well as arbitrary cross-sectional images, of the pancreatic ducts. The method is simple, not uncomfortable, and requires no contrast media. Magnetic resonance cholangiopancreatography (MRCP) was initially developed as a substitute for ERCP for diagnosis of pancreatic disorders such as neoplasm and chronic pancreatitis, but the method offers advantages other than safety and flexibility. MRCP may be the diagnostic method of choice when ERCP is contraindicated or fails. Imaging after injection of secretin may add functional information to MRCP that may reflect one aspect of pancreatic exocrine physiology. Adequate diagnostic evaluation of acute pancreatitis, pancreatic trauma, and mucinous ductal ectasia may also be feasible. Innovations such as fast sequences with breath-holding, receiver multicoils, high-power gradient systems, and postprocessing will further refine the technique. Optimized MRCP could limit indications for diagnostic endoscopic pancreatography substantially.     

Pathophysiologic studies of experimental chronic pancreatitis in rats induced by injection of zein-oleic acid-linoleic acid solution into the pancreatic duct

An experimental model of chronic pancreatitis was induced by a retrograde injection of a viscous solution consisting of zein-oleic acid-linoleic acid (0.05 ml/100 g body weight) into the rat pancreatic duct. Histologic and biochemical changes were investigated over a period of 6 months after induction of this model. The treated rats gained weight, but pancreatic weight decreased with time. Histologically, the widening of acinar lumen and cellular vacuolization occurred within 24 h at the parenchyma neighboring the small ducts filled with the injected solution. Degenerative parenchyma, interstitial edema, and inflammatory cell infiltration were pronounced 1 week later. Thereafter, duct-like tubular complex formation progressed, and the exocrine tissue exhibited marked atrophy of the gland with irregular fibrosis and fat replacement over a period of 6 months. Pancreatic contents of protein, amylase, DNA, and RNA markedly decreased, as did pancreatic weight, whereas hydroxyproline content increased. Oral administration of camostat did not affect pancreatic weight and contents of enzyme in this model. Urinary para-aminobenzoic acid (PABA) excretion in the BT-PABA test decreased to 54% at 6 weeks and 22% at 6 months. Although three quarters of pancreatic immunoreactive insulin (IRI) content was lost after 6 months, overt diabetes did not occur. The results suggest that an obstructive mechanism in the small ducts plays an important role in the genesis and development of chronic pancreatitis.     

Treatment of angiographically produced cord seizures by intra-arterial diazepam

Motilin and secretin were compared in regard to their effects on pancreatic bicarbonate and protein secretion in conscious dogs provided with chronic pancreatic fistulas. Dose-response analysis showed that maximal bicarbonate response to motilin was about 5% of that to secretin and maximal protein response was about 35% of that to caerulein. The interaction of these two peptides showed that motilin is a potent inhibitor of secretin-induced bicarbonate secretion. Since motilin is released by duodenal alkalinization and inhibits pancreatic bicarbonate secretion, it is possible that this peptide is involved in the feedback mechanism of inhibition of pancreatic secretion by alkaline pancreatic juice present in the duodenum.     

Clinical application of a new mobile integrated orbital implant]

Uraemic pancreatopathy is frequently observed in patients with chronic renal failure. The aim of the study was to assess some parameters of exocrine pancreatic function in uraemic patients maintained on intermittent haemodialyses. Elevated serum amylase activity was found in these patients. The most significant finding was the low bicarbonate output in duodenal content after secretin-cerulein stimuli, comparable with that obtained in patients with chronic pancreatitis. It indicates pancreatic exocrine defect in uraemic patients. A fall in protein output and lower amylase activity in duodenal content was also observed in haemodialyzed patients after stimulation. Low basal acid output (BAO) and enhanced maximal (MAO) and peak (PAO) acid outputs were found in uraemic patients after pentagastrin stimulation. Gastritis and duodenitis were frequently diagnosed in endoscopic and histopathological examinations in these patients. In patients with chronic renal failure even without clinical signs of pancreatic, laboratory findings of exocrine pancreatic abnormalities are reported. It may be the cause of uraemic pancreatopathy.     

Effect of irradiation on the canine exocrine pancreas

Effects of irradiation on the pancreas was studied in 6 dogs receiving a dose equivalent to the biologic effect of 4000 R/6 weeks (with a nominal stnadard dose of 1175 rets) given to patients with Hodgkins disease. After control secretory, histologic and pancreatographic studies, 6 Thomas fistula dogs were subjected to 2400 R tumor dose over two weeks. There was a biphasic response to secretin alone or secretin with cholecystokininpancreozymin. An initial hypersecretion occurred at 2 weeks --volume was increased, but bicarbonate and enzyme output remained unchanged. Thereafter there was a progressive reduction in volume, bicarbonate and enzyme outputs ( greater than 90% after 3 months). Histology showed early ductal reduplication but with progressive fibrosis, features compatible with chronic pancreatitis. Pancreatic insufficiency may contribute to post-irradiation gastrointestinal symptomatology. Close field irradiation of the pancreas results in actual destruction of the parenchyma.     

Effect of granulocyte colony-stimulating factor on the course of infection with gram-positive bacteria in mice during granulocytopenia induced by sublethal irradiation or cyclophosphamide

Ligation of the common bile-pancreatic duct induces hyperamylasemia and acute pancreatitis in rats. Pancreatic morphologic changes include edema, acinar cell damage, and mild inflammation. The pathogenesis of acute pancreatitis in this model is not understood, but may involve altered secretion and intrapancreatic activation of acinar proteases. We hypothesized that trypsinogen activation, measured by the production of plasma and pancreatic trypsinogen activation peptides (TAP), occurs early in this model. We performed the following experiments: rats were prepared with (1) bile-pancreatic ducts ligated and (2) ducts dissected but not ligated (sham). Rats were killed after 6, 24, and 48 hr. Serum amylase was measured and histologic sections were analyzed for morphologic changes. TAP was measured in both serum and pancreatic tissue homogenates using a specific polyclonal. anti-TAP antibody in an enzyme-linked immunosorbant assay. After 6, 24, and 48 hr of bile-pancreatic duct ligation, hyperamylasemia and acute morphologic changes of acute pancreatitis were observed. Evidence of acinar cell destruction was not evident until 48 hr after ligation. Levels of serum and pancreatic tissue TAP were significantly elevated at both 24 and 48 hr after ligation compared to those of sham. We conclude that increased intrapancreatic trypsinogen activation occurs early in this form of experimental acute pancreatitis and that it occurs prior to evidence of acinar cell destruction. These data and observations support the possibility that intrapancreatic protease activation contributes to the pathogenesis of ligation-induced acute pancreatitis.     

Prospective study of the 1st 197 endoscopic retrograde cholangio-pancreatographies (ERCP) in Basel (1973-1975)

Cannulation of the papilla has been successful in 144 out of 197 ERCPs. The rate of success increases with the experience of the endoscopist. The intended filling of the pancreatic duct was successful in 87%, of the bile ducts in 64% and of both duct systems in 28%. The correct diagnosis was made in 77% of pancreatic affections, 71% of biliary diseases and in 43% when both duct systems had to be evaluated. 10 ERCP findings disagreed with the final diagnosis, mainly because the distinction between acute and chronic pancreatitis was not correct. The differentiation of chronic pancreatitis from pancreatic carcinoma is not easy and the evaluation of processes localized to the papilla may be difficult. Complications occurred in 6.6%. It is concluded that the ERCP should be limited to regional hospital centers and should be performed only in cases with well defined indications.     

Chronic pancreatitis: diagnosis

Chronic pancreatitis is a chronic, inflammatory process leading to destruction of the exocrine tissue, filorosis, and in some patients a loss of endocrine function. Because chronic pancreatitis results in a permanent destruction of pancreatic tissue, exocrine and/or endocrine pancreatic insufficiency may follow. However, owing to the tremendous reserve of pancreatic function, insufficiency may be subclinical at least in the beginning of the disease. The diagnosis of chronic pancreatitis is not difficult; it is based on a typical medical history, specific imaging procedures, and pancreatic function testing. The main differential diagnosis is to separate chronic pancreatitis form pancreatic carcinoma. In the present summary, the different imaging procedures and pancreatic function tests are discussed.