Influence of extrapancreatic digestive disorders on the indirect pancreatic function test with fluorescein dilaurate

The detection rate of pancreatic disease using the indirect pancreatic function test with orally administered substrate fluorescein dilaurate (FDL) was evaluated in 290 patients. The sensitivity of the test was 84% in chronic pancreatitis (99 patients). Results were abnormal in all 5 patients with advanced pancreatic cancer and in 3 of 19 patients tested after a single episode of acute pancreatitis. The specificity of the FDL test was 89% when healthy subjects or patients with functional gastrointestinal disorders served as controls. However, it dropped to 62% when all patients with different organic gastrointestinal disorders were considered. This decrease could be attributed to patients with subtotal gastric resection and extensive small bowel disease, who were found to have the highest of pathological FDL test results, i.e., 70 and 35%, respectively. Not restricting the oral FDL test to the detection of primary pancreatic disease, in subtotal gastrectomy and extensive small bowel disease this test provides the opportunity to detect secondary pancreatic dysfunction.     

Pancreatic Duct Patterns in Acute Pancreatitis: A MRI Study

Objectives

To study the MRI findings of the pancreatic duct in patients with acute pancreatitis.

Materials and Methods

A total of 239 patients with acute pancreatitis and 125 controls were analyzed in this study. The severity of acute pancreatitis was graded using the MR severity index (MRSI) and the Acute Physiology And Chronic Healthy Evaluation II(APACHE II) scoring systems. The number of main pancreatic duct (MPD) segments visualized, and both MPD diameter and pancreatic duct disruption were noted and compared with the severity of acute pancreatitis.

Results

The frequency of MPD segment visualization in the control group was higher than that in the acute pancreatitis group (p<0.05). The number of MPD segments visualized was negatively correlated with the MRSI score (p<0.05) and the APACHE II score (p<0.05). There was no difference in the MPD diameter between the acute pancreatitis and control groups or among the patients with different severities of acute pancreatitis (p>0.05). The prevalence of pancreatic duct disruption was 7.9% in the acute pancreatitis group. The prevalences of pancreatic duct disruption were 4.8% and 15.3% in the mild and severe acute pancreatitis groups based on the APACHE II score, respectively, and were 0%, 5.7% and 43.5% in the mild, moderate and severe acute pancreatitis groups according the MRSI score, respectively. The prevalence of pancreatic duct disruption was correlated with the severity of acute pancreatitis based on the APACHE II score (p<0.05) and MRSI score (p<0.05).

Conclusion

The pancreatic duct in acute pancreatitis patients was of normal diameter. The number of MPD segments visualized and visible pancreatic duct disruption on MRI may be supplementary indicators for determining the severity of acute pancreatitis.     

胰腺外分泌细胞的适应性细胞保护作用

用5％牛磺胆酸钠-胰蛋白酶溶液作为强刺激物直接注入大鼠胰导管系统,制成急性出血坏死性胰腺炎模型。若于48h前向胰导管内预先给予0.1％、0.2％或0.4％的低浓度牛磺胆酸钠-胰蛋白酶溶液作为弱刺激物,能使随后给予的强刺激物所致的损伤大大减轻,使病鼠死亡率由对照组的100％分别降低到27％、17％和17％;血清淀粉酶浓度升高的幅度由对照组的4680U/100ml血清降低到1990、2180和2710U/100ml血清。胰腺组织学切片检查可见,病变由急性出血坏死性胰腺炎转变为轻度急性胰腺炎或向慢性胰腺炎转化。这项结果提示:预先给予弱刺激可使胰腺外分泌细胞对随后给予的强刺激产生适应性细胞保护作用,其机制尚待探索。     

Alcohol and Acute Pancreatitis

Alcohol abuse is associated with the development of both acute and chronic pancreatitis. The majority of patients who abuse alcohol will not develop pancreatitis; the reasons for different susceptibilities to alcohol are unknown. Most patients who present with acute alcoholic pancreatitits will have underlying chronic disease, but up to a third will have no evidence of chronic pancreatitis. Alcohol has a number of acute effects on the pancreas that are potentially toxic. These include increasing pancreatic duct pressure, decreasing pancreatic blood flow, generating free radicals, and stimulating pathologic zymogen activation within the pancreatic acinar cell.     

Metabolomic analysis to discover candidate therapeutic agents against acute pancreatitis

Novel and effective drugs against acute pancreatitis are required. Therefore, we examined the changes in the metabolite levels in the serum and pancreatic tissue of mice with cerulein- and arginine-induced pancreatitis using gas-chromatography/mass-spectrometry (GC/MS) and investigated whether these alterations affected the severity of acute pancreatitis. In the cerulein-induced pancreatitis model, 93 and 129 metabolites were detected in the serum and pancreatic tissue, respectively. In the L-arginine-induced acute pancreatitis model, 120 and 133 metabolites were detected in the serum and pancreatic tissue, respectively. Among the metabolites, the concentrations of tricarboxylic acid (TCA) cycle intermediates and amino acids were altered in pancreatitis, and in pancreatic tissue, the levels of the intermediates involved in the initial part of the TCA cycle were increased and those of the intermediates involved in the latter part of the TCA cycle were decreased. Some metabolites exhibited similar changes in both pancreatitis mouse models, e.g., the levels of glutamic acid and O-phosphoethanolamine were significantly decreased in the pancreatic tissue. Supplementation with glutamic acid and O-phosphoethanolamine attenuated the severity of cerulein-induced acute pancreatitis. Our results suggest that GC/MS-based metabolomics is capable of accurately representing the status of acute pancreatitis, leading to the discovery of therapeutic agents for pancreatitis.     

Platelet activating factor (PAF) inhibitor (TCV-309) reduces caerulein- and PAF-induced pancreatitis. A morphologic and functional study in the rat.

Caerulein-induced acute pancreatitis was studied in rats. Consistent with this type of acute pancreatitis morphological (edema, leukocytic infiltration and acinar cell vaculization) and biochemical (increase in pancreatic protein content. PAF release and serum amylase) changes developed 5 hours after caerulein administration. In addition increase in pancreatic weight and decrease in pancreatic blood flow were noticed. PAF administration caused pancreatic damage similar in some parameters to caerulein-induced pancreatitis, along with reduction of pancreatic blood flow, increase in pancreatic protein content, and serum amylase. TCV-309, a selective PAF antagonist, administered prior to caerulein and/or PAF, reduced caerulein-induced pancreatitis and prevented PAF-induced pancreatitis. Results of our present studies indicate the crucial role of PAF in pathogenesis of experimental acute pancreatitis.     

The monoclonal antibody-defined CAR-3 antigen is a serological marker associated with pancreatic carcinoma

The monoclonal antibody-defined CAR-3 antigen is a new carcinoma associated marker which is expressed on a mucin-like molecule. Serum concentrations of CAR-3 were assayed in 181 patients with carcinomas of different organs, 20 patients with non-carcinomatous malignancies, 123 patients with inflammatory diseases and 150 healthy controls. Serum levels of CAR-3 were significantly increased in 51% of the patients with pancreatic carcinomas, in 60% of patients with biliary tract carcinomas and in about 15% of the patients with carcinomas of the digestive apparatus. Sera from patients with breast carcinomas were negative, as well as sera from patients with melanomas or sarcomas. CAR-3 values in samples from patients with chronic pancreatitis were constantly negative, as were samples from healthy donors. Significant concentrations of CAR-3 were detected in 20% of the sera from patients with acute pancreatitis and in 15% of the sera from patients with cirrhosis. Because of its high specificity for pancreatic carcinomas compared to chronic pancreatitis, CAR-3 seems a promising marker for distinguishing between neoplastic and chronic inflammatory diseases of the pancreas, whose differential diagnosis is difficult.     

Expression profiling in pancreas during the acute phase of pancreatitis using cDNA microarrays

Most attacks of acute pancreatitis are self-limiting, suggesting that the pancreatic cells adapt their phenotype to prevent progression of the disease. Such phenotypic change must involve a coordinated modification in the expression of numerous genes. To identify differentially expressed genes, high-density mouse cDNA microarrays were hybridized with cDNA probes from both healthy pancreas and pancreas affected by acute pancreatitis. From the 7981 mouse genes analyzed, 239 showed significant changes in their expression during the acute phase of pancreatitis. Among them, 107 genes were up-regulated whereas 132 were down-regulated. They include genes whose function was not previously related to pancreatitis, suggesting that they are involved in some way into the acute pancreatic response. Finally, 40% of differentially expressed genes corresponded to ESTs. Demonstration that a large quantity of unexpected or yet uncharacterized genes showed altered expression during acute pancreatitis underscores the interest of a genome-based investigation. Some of these genes are certainly involved in the cellular defense against pancreatitis and, as such, deserve being studied further.     

Management of necrotizing pancreatitis.

A comprehensive management plan is presented for patients with severe acute pancreatitis. These patients may have pancreatic or peripancreatic necrosis or pancreatic fluid collections. Multiple organ failure often develops in patients with severe pancreatitis. We therefore recommend that all patients with acute pancreatitis be evaluated for pancreatic anatomy and function. If a patient is seriously ill, a computed tomographic (CT) scan with vascular enhancement should be done. Meanwhile, vigorous fluid replacement is necessary using Swan-Ganz monitoring. Patients with necrosis do not need surgical intervention unless the clinical course or CT scan-guided aspiration shows infection. The objective of an operation should be to remove all infected tissue and fluid. A preoperative CT scan with vascular enhancement should be used as a guide during the operation to ensure that all foci of infected necrosis or fluid are eliminated. We have found that open packing and irrigation with sodium oxychlorosene are helpful in patients with extensive necrosis or those who become infected early after the onset of symptoms. In all, 40% to 50% of patients treated by closed drainage will require reoperation because of incomplete debridement. Persistent sepsis is an indication for reoperation.     

Perfusion-CT - Can We Predict Acute Pancreatitis Outcome within the First 24 Hours from the Onset of Symptoms?

Purpose

Severe acute pancreatitis (AP) is still a significant clinical problem which is associated with a highly mortality. The aim of this study was the evaluation of prognostic value of CT regional perfusion measurement performed on the first day of onset of symptoms of AP, in assessing the risk of developing severe form of acute pancreatitis.

Material and Methods

79 patients with clinical symptoms and biochemical criteria indicative of acute pancreatitis (acute upper abdominal pain, elevated levels of serum amylase and lipase) underwent perfusion CT within 24 hours after onset of symptoms. The follow-up examinations were performed after 4–6 days to detect progression of the disease. Perfusion parameters were compared in 41 people who developed severe form of AP (pancreatic and/or peripancreatic tissue necrosis) with parameters in 38 consecutive patients in whom course of AP was mild. Blood flow, blood volume, mean transit time and permeability surface area product were calculated in the three anatomic pancreatic subdivisions (head, body and tail). At the same time the patient''s clinical status was assessed by APACHE II score and laboratory parameters such as CRP, serum lipase and amylase, AST, ALT, GGT, ALP and bilirubin were compared.

Results

Statistical differences in the perfusion parameters between the group of patients with mild and severe AP were shown. Blood flow, blood volume and mean transit time were significantly lower and permeability surface area product was significantly higher in patients who develop severe acute pancreatitis and presence of pancreatic and/or peripancreatic necrosis due to pancreatic ischemia. There were no statistically significant differences between the two groups in terms of evaluated on admission severity of pancreatitis assessed using APACHE II score and laboratory tests.

Conclusions

CT perfusion is a very useful indicator for prediction and selection patients in early stages of acute pancreatitis who are at risk of developing pancreatic and/or peripancreatic necrosis already on the first day of the onset of symptoms and can be used for treatment planning and monitoring of therapy of acute pancreatitis. Early suspicion of possible pancreatic necrosis both on the basis of scores based on clinical status and laboratory tests have low predictive value.     

The estrogen binding protein in human pancreas: concentrations in subcellular fractions of normal pancreatic tissue, in duodenal juice during pancreatic stimulation and in peripheral serum in normal and pathological conditions

The steroid binding properties of the human pancreatic estrogen binding protein (hEBP) in cytosol were studied by equilibrium dialysis. A high ligand specificity of the protein was revealed. hEBP in cytosol binds unconjugated steroid estrogens with a medium affinity (Kd = 10(-7) M) but does not bind conjugated estrogens or unconjugated androgens, gestagens, glucocorticoids or cholesterol. Quantitation of hEBP by radioimmunoassay in subcellular fractions of human pancreatic tissue indicated that the protein is translocated into different subcellular compartments. Duodenal juice taken from patients following stimulation of pancreatic secretion by food ingestion (Lund's test) showed high hEBP concentrations, and the levels of hEBP changed concomitantly with the levels of pancreatic isoamylase, indicating that hEBP secretion was stimulated by food ingestion. The levels of hEBP in peripheral serum from healthy subjects showed no sex difference, but were positively correlated to age. Highly elevated (10-20-fold) hEBP levels were found in serum from patients with acute pancreatitis, while normal serum hEBP values were found in other abdominal diseases. It is speculated that hEBP might have a specific role in the transport of estrogens from the peripheral circulation via the pancreas to the duodenum. The elevated hEBP levels in patients with acute pancreatitis indicate that this protein may be used as a marker of cellular damage in the pancreas.     

Effects of gabexate mesilate on serum inflammatory cytokines in rats with acute necrotizing pancreatitis

Gabexate mesilate is a synthetic protease inhibitor. The effectiveness of gabexate mesilate in patients with acute pancreatitis is controversial. Proinflammatory cytokines are associated with systemic inflammatory response syndrome (SIRS) in acute pancreatitis. A compensatory anti-inflammatory response occurs in parallel with SIRS. We investigated the effects of gabexate mesilate on acute necrotizing pancreatitis in rats, emphasizing the changes in serum levels of proinflammatory and anti-inflammatory cytokines. Acute necrotizing pancreatitis was induced by retrograde infusion of sodium taurodeoxycholate into the pancreatobiliary duct in rats. The rats were divided into three groups. Group I was given gabexate mesilate 2 mg/kg/h i.v. continuously 1 h before the induction of acute pancreatitis. Group II was given gabexate mesilate the same dose immediately after the induction of acute pancreatitis. Group III was given normal saline as the controls. Serum levels of amylase, lipase, tumor necrosis factor alpha, interleukin-6, and interleukin-10, pancreatic histopathology and hemodynamics were examined at 5h after the induction of acute pancreatitis. Gabexate mesilate significantly reduced serum levels of amylase, lipase, tumor necrosis factor alpha and interleukin-6 at 5 h. Serum levels of interleukin-10 significantly increased in Group I, as compared with Groups II and III. The severity of pancreatic histopathology, the reduction of mean arterial pressure, the volume of ascites and pancreatic wet weight/body weight ratios were also significantly improved by the administration of gabexate mesilate. The beneficial effects of gabexate mesilate on acute pancreatitis may be, in part, due to the modulation of inflammatory cytokine responses.     

Prediction of Severe Acute Pancreatitis Using a Decision Tree Model Based on the Revised Atlanta Classification of Acute Pancreatitis

Objective

To develop a model for the early prediction of severe acute pancreatitis based on the revised Atlanta classification of acute pancreatitis.

Methods

Clinical data of 1308 patients with acute pancreatitis (AP) were included in the retrospective study. A total of 603 patients who were admitted to the hospital within 36 hours of the onset of the disease were included at last according to the inclusion criteria. The clinical data were collected within 12 hours after admission. All the patients were classified as having mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) based on the revised Atlanta classification of acute pancreatitis. All the 603 patients were randomly divided into training group (402 cases) and test group (201 cases). Univariate and multiple regression analyses were used to identify the independent risk factors for the development of SAP in the training group. Then the prediction model was constructed using the decision tree method, and this model was applied to the test group to evaluate its validity.

Results

The decision tree model was developed using creatinine, lactate dehydrogenase, and oxygenation index to predict SAP. The diagnostic sensitivity and specificity of SAP in the training group were 80.9% and 90.0%, respectively, and the sensitivity and specificity in the test group were 88.6% and 90.4%, respectively.

Conclusions

The decision tree model based on creatinine, lactate dehydrogenase, and oxygenation index is more likely to predict the occurrence of SAP.     

Surgical Treatment of Necrotizing Pancreatitis

Surgical treatment in patients with severe acute pancreatitis is still a controversial subject, ranging from sole conservative to an aggressive approach. This article gives an overview of the literature with regard to indications for surgery, timing and techniques of operative treatment concepts in severe acute pancreatitis with special attention to the recommended necrosectomy and closed continuous lavage of the involved retroperitoneum. Taking into account recent findings from microbiological data we have developed a new algorithm in patients with acute pancreatitis. All patients with proven acute necrotizing pancreatitis receive an antibiotic therapy for 2 weeks beside the intensive care measures. So far only one third (33 percent) had infected pancreatic necroses in the 3rd week of the onset of the disease and were managed surgically. The delay resulted in optimal surgical conditions for necrosectomy and a mortality rate of 9 percent. This new concept and therapeutic approach with the early suitable antibiotic therapy in patients with proven necrotizing pancreatitis is recommended to (1) decrease the infection rate and (2) delay surgical intervention to the 3rd week of the disease with optimal surgical conditions. It seems that only patients with proven infected pancreatic necroses are candidates for surgical intervention.     

胆囊切除术后急性胰腺炎患者314例的发病特点分析

目的:研究胆囊切除术后患者发生急性胰腺炎的发病特点。方法:回顾性分析2009年10月至2013年10月四川大学华西医院诊断为急性胰腺炎且既往行胆囊切除术患者的病因、病情严重程度、临床特征与转归。结果:研究共纳入314例患者,以高脂血症性胰腺炎占比最高,共110例(35%),胆源性胰腺炎和混合性胰腺炎分别为107例(32%)、96例(31%),酒精性仅7例(2%)。轻症215例,中度31例,重度68例。高脂血症性胰腺炎患者重症率(36%)、胰腺及胰周坏死率(28%)、持续性器官功能衰竭率(36%)、呼吸衰竭率(41%)、ICU转入率(26%)均显著高于胆源性组和混合组,差异具有统计学意义(P0.05)。结论:胆囊切除后的急性胰腺炎以胆源性胰腺炎和高脂血症性胰腺炎居多,其中高脂血症性胰腺炎的病情更严重。     

Zinc and copper status in acute pancreatitis: an experimental study

Metal ions are required as active components of several proteins, including pancreatic enzymes, and they can play important roles in the etiopathogenesis of acute pancreatitis. In the present study, we measured the concentrations of zinc (Zn) and copper (Cu) in both serum and pancreatic tissue, as markers of trace element status in an experimental acute pancreatitis model. Twenty-four male Wistar rats were divided into two groups: the experimental group (N=24) and the control group (N=10). Acute pancreatitis was induced by injection of 48% ethyl alcohol into the common biliary duct. The animals were sacrificed 24 h later to detect the concentrations of Zn and Cu. There was no significant difference in tissue Zn and Cu concentrations between control and experimental groups (p<0.05). However, in the acute pancreatitis group, serum Zn and Culevels were very significantly lower (p<0.001 and p<0.0001, respectively). In conclusuion, these findings suggested that altered mineral metabolism in serum and pancreatic tissue may have contributed to the pathophysiology of acute pancreatitis.     

The naïve effector cells of collagen type I during acute experimental pancreatitis are acinar cells and not pancreatic stellate cells

Objective

The purpose of this study was to investigate the expression of collagen type I and the mRNA level of its regulatory factor, TGF-β1, in tissue samples of acute pancreatitis and to determine the significance of collagen type I in predisposition to pancreatic fibrosis during acute pancreatitis.

Methods

Sprague–Dawley rats were divided into an experimental group (30 rats) and a control group (12 rats). The rats in the experimental group were intraperitoneally injected with cerulein to induce acute pancreatitis. The distribution and expression of collagen type I in the pancreatic tissues were examined by immunohistochemical staining. The mRNA level of TGF-β1 was determined by real-time polymerase chain reaction (PCR).

Results

(1) Collagen type I was localized in the cytoplasm of pancreatic acinar cells. With pancreatitis progressed, strong positive staining for collagen type I covered whole pancreatic lobules, whereas, the islet tissue, interlobular area, and pancreatic necrotic area were negative for collagen type I. (2) The level of TGF-β1 mRNA in rats from the experimental group increased gradually the establishment of acute pancreatitis, and was significantly higher than that in the control group at every time point.

Conclusions

(1) During acute pancreatitis, pancreatic acinar cells, not pancreatic stellate cells as traditionally believed, were the naïve effector cells of collagen type I. (2) TGF-β1 played a key role in regulating collagen I expression during acute pancreatitis.     

Prospective comparison of three non-invasive tests for pancreatic disease.

Ultrasonography, computed tomography (CT), and an oral pancreatic function test were evaluated prospectively in 107 consecutive patients suspected of having pancreatic disease, the final diagnosis being made independently of these tests. Seventeen patients proved to have either chronic pancreatitis or a pancreatic neoplasm. Five had an unfused ventral pancreas and 10 had "minimal change" pancreatograms. Seventy five patients did not have pancreatic disease. Among the 17 patients with pancreatic disease the sensitivities of ultrasound, CT, and the pancreatic function test were 70%, 71%, and 76% respectively; among those without disease values of specificity of the three tests were 75%, 87%, and 72%. All three tests failed to detect most of the patients with unfused ventral pancreases or minimal change pancreatograms. The predictive values of a positive result for the three tests were 43%, 67%, and 34%. The predictive value of a negative result was greater than 90% for all the tests. Results improved when CT was combined with either of the two other tests. These findings show that CT is the most accurate of the three tests in diagnosing pancreatic disease but that a combination of ultrasound and the oral pancreatic function test offers a more widely applicable and almost as accurate alternative.     

Diabetes mellitus and the exocrine pancreas

Diabetes and carbohydrate intolerance can occur in pancreatitis. Although one-half of patients with acute pancreatitis will have some evidence of glucose intolerance during their acute illness, few will require insulin administration on either a short- or long-term basis. The diabetes seen in acute pancreatitis is likely due to a combination of factors, including alerted insulin secretion, increased glucagon release, and decreased glucose utilization by the liver and peripheral tissue. Chronic pancreatitis is often associated with diabetes mellitus, with the incidence as high as 70 percent when pancreatic calcification is present. These patients tend to be very sensitive to the effects of insulin and hypoglycemia. This is probably secondary to concurrent hepatic disease, malnutrition, and a relative decrease in glucagon reserves. The diabetes seen in chronic pancreatitis is associated with decreased insulin production. Finally, although the endocrine pancreas may influence the exocrine gland through a portal system, primary diabetes mellitus probably does not result in clinically significant alterations in pancreatic exocrine function.