Simultaneous Combined Pancreatic Test

A simultaneous combined pancreatic test can be performed in one morning with only one intubation of the duodenum. The test includes the measurement of exocrine pancreatic secretion of bicarbonate, enzymes, and radioactive selenium, pancreatic scanning, hypotonic duodenography, and cytology of the duodenal aspirate. In the first 70 patients it was found that a single secretion test was of only limited value in detecting pancreatic disease; cytology was the most reliable and scanning the least reliable single test; and that the combined test provided near-complete discrimination between patients with no pancreatic disease, with chronic pancreatitis, and with carcinoma of the pancreas.     

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 Exocrine Function in Maturity Onset Diabetes Mellitus

Exocrine pancreatic function was studied in 14 inpatients with newly diagnosed maturity onset diabetes mellitus. Five patients had clinical and biochemical evidence of pancreatic disease (two carcinoma, three pancreatitis). The other nine patients had no clinical pancreatic disease but all except one had at least one abnormal result of pancreatic function tests. None of this group with idiopathic diabetes mellitus developed any clinical evidence of exocrine pancreatic disease over the next five years. Mild abnormalities of exocrine pancreatic function in newly diagnosed patients with diabetes but without clinical evidence of pancreatic disease do not usually develop into overt pancreatic disease, and are therefore probably clinically unimportant.     

Radioselenium in Duodenal Aspirate as an Assessment of Pancreatic Exocrine Function

A new test of pancreatic exocrine function is described in which radioselenium is measured in duodenal aspirate after an intravenous injection of ⁷⁵Se-selenomethionine and administration of a Lundh test meal. Duodenal ⁷⁵Se activity gave good separation between normals and subjects with disease of the exocrine pancreas and correlated well with trypsin levels in the aspirate.     

Effect of somatostatin on exocrine pancreatic secretion stimulated by pancreozymin-secretin or by a test meal in the dog

In 4 dogs with chronic duodenal and gastric fistulae, exocrine pancreatic function was assessed by cannulating the pancreatic duct and collecting the duodenal contents. Both methods were applied in each animal. Pancreatic secretion was stimulated by infusion of 2 CHR units of pancreozymin and secretin or by administration of a liquid test meal, injected into the stomach through the gastric fistula. During both experiments 3.5 microgram/kg somatostatin was given as bolus injection followed by an infusion of 3.5 microgram/kg/h. Somatostatin caused a significant reduction in protein and amylase output and in the bicarbonate concentration during stimulation with pancreozymin-secretin. Volume and bicarbonate slightly decreased but not to a significant extent. Duodenal volume and the duodenal activities of trypsin and amylase were significantly reduced during test meal stimulation and somatostatin infusion. Somatostatin is a potent inhibitor of exocrine pancreatic function mainly influencing enzyme secretion.     

Symposium on diarrhea. 3. Investigation of chronic diarrhea.

The practical approach to the investigation of diarrhea must be logical and based on anatomic considerations. The site of the underlying disorder may be determined by the clinical picture, and the logic of investigation will be influenced by the history. Important specific investigation in a case of colonic diarrhea include a careful rectal examination, stool inspection, sigmoidoscopy, rectal biopsy and barium enema study. Colonoscopy has been used, but its role has yet to be defined. In a case of small-bowel steatorrhea or diarrhea quantitative chemical estimation of the daily output of stool fat is useful, and to this investigation is added a small-bowel radiograph series and, if the radiographic findings are abnormal, small-bowel biopsy. Other investigations for small-bowel disease may include the breath test with carbon-14-labelled glycocholic acid, the lactose tolerance test, duodenal aspiration for giardiasis, analysis of serum immunoglobulins and, on occasion, isolation of vasoactive intestinal polypeptide hormone (which may aid the diagnosis of functioning tumours of the pancreas or small bowel). Investigations for pancreatic steatorrhea include abdominal radiography, performance of the secretin test and testing of the response to pancreatic replacement therapy. In some patients it may be useful to use endoscopic retrograde cholangiopancreatography to differentiate pancreatic carcinoma and chronic pancreatitis.     

Assessment of cholesterol esterase activity in the duodenal contents of man

In 20 healthy patients the cholesterol esterase activity in duodenal content was examined. The cholesterol ether of o-coumaric acid was used as a substrate. Increase of the cholesterol esterase activity was noted after stimulation of pancreozymin and secretin. The cholesterol esterase concentration in duodenal content changes in more wide range than the index of the output. The cholesterol esterase output is the most significant informative index. There is not any cholesterol esterase activity in bile, gastric juice and saliva. The results obtained have shown that the main part of the estimated cholesterol esterase activity has a pancreatic base. The investigation of the cholesterol esterase activity in duodenal content may be used in the study of the exocrine function of pancreas.     

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.     

The effect of oxyntomodulin (Glucagon-37) and glucagon on exocrine pancreatic secretion in the conscious rat

The inhibitory effect of glucagon on exocrine pancreas has been the subject of controversial reports. On the other hand, oxyntomodulin (bioactive enteroglucagon or glucagon-37), a 37 amino acid peptide isolated from porcine lower intestine, has been shown to be 10–20 times more potent than glucagon in inhibiting gastric acid secretion in the rat. In view of this, the effect of glucagon and oxyntomodulin on basal and caerulein-stimulated pancreatic secretion has been studied, during re-introduction of pancreatic juice into duodenum, in the conscious rat provided with pancreatic and duodenal fistulas. A depression of pancreatic function was observed with both peptides on the three parameters studied: (volume of juice secreted, bicarbonate and protein output), either under basal conditions or during stimulation by caerulein. In all the experimental conditions used, oxyntomodulin was ca. ten times more potent than glucagon in its inhibitory effect. The fact that oxyntomodulin, as what is observed in the stomach, is one order of magnitude more potent than glucagon in inhibiting pancreatic secretion suggests that the biological mechanisms by which the peptides of the glucagon-family act on exocrine pancreas are similar, or related to that present at the gastric level.     

Effect of glucagon on canine exocrine pancreatic secretion stimulated by a test meal

The effect of glucagon on exocrine pancreatic secretion stimulated by a test meal was studied in three dogs with a chronic gastric fistula and a modified Thomas duodenal fistula which allows easier collection of pure pancreatic juice after a meal. Glucagon was given by continuous intravenous infusion in doses of 5, 10, 15, or 30 microgram/kg per hour, before and during a test meal. At each dose level glucagon significantly reduced the water and electrolyte secretion of the pancreas. At 15 and 30 microgram/kg per hour glucagon inhibited protein output; this effect was absent at lower doses. These findings demonstrate a dose-dependent inhibition by glucagon of the pancreatic bicarbonate and protein response to a meal. Inhibition of bicarbonate output was more sensitive to glucagon than that of protein output.     

Fecal Chymotrypsin and Trypsin Determinations

Trypsin and chymotrypsin concentrations were determined in 180 spot stool specimens from 110 control patients in hospital. The lower limit of normality for each enzyme was placed at the 5% level: 95% of this population excreted feces containing more than 100 μg. of chymotrypsin and 30 μg. of trypsin per g. of feces. Chymotrypsin concentrations appeared to be a more reliable guide to pancreatic function than trypsin concentrations.Fecal chymotrypsin concentrations were subnormal in five patients with chronic pancreatitis, borderline in one patient with relapsing pancreatitis, subnormal in one patient after pancreatectomy, and subnormal in five of nine with carcinoma of the pancreas. Subnormal concentrations of fecal chymotrypsin were found in seven of 21 patients with chronic liver disease related to alcoholism, eight of 32 with a partial gastrectomy, three of 10 with adult celiac disease and five of 16 with psoriasis.It appears that the determination of fecal chymotrypsin concentrations provides a valuable screening test for pancreatic exocrine deficiency. However, normal results may be found in some patients with pancreatic disease and subnormal values may occur in some patients with other conditions.     

Role of peptide YY in regulation of duodenal motility during the interdigestive period in sheep

Temporal coordination between duodenal migrating myoelectric complexes (MMC) and pancreatic exocrine secretion, and the effects of porcine peptide YY (PYY) on gastroduodenal motility and pancreatic exocrine secretion were examined during the interdigestive period in conscious mature sheep. Fluid and enzyme secretions from the exocrine pancreas showed a periodic pattern corresponding to the phases of duodenal MMC, although these secretion rates were maintained at a high level during phase II in sheep. Intravenous continuous infusion of PYY at doses ranging from 50 to 200 pmol · kg⁻¹ · h⁻¹ or intravenous bolus infusion of PYY at doses ranging from 50 to 200 pmol · kg⁻¹ showed a tendency to prolong the first cycle of the duodenal MMC and significantly shorten the second cycle. However, there was almost no effect on ruminal contractions from the PYY administration. In the pancreatic exocrine secretion, PYY could inhibit only bicarbonate secretion at only the highest dose of 200 pmol · kg⁻¹. These results imply that endogenous PYY may play a physiological role in the regulation of the duodenal MMC cycles in sheep but not in ruminal contractions. PYY seems unlikely to regulate the pancreatic exocrine secretion in normal sheep, because a supraphysiological dose of PYY was required to inhibit the pancreatic exocrine secretion. Accepted: 3 March 1997     

Effect of nitric oxide synthase inhibitors on the temporal coordination of duodenal contractions and pancreatic exocrine secretion in sheep

The present study evaluated the role of nitric oxide in the regulation of duodenal motility and pancreatic exocrine secretion in conscious sheep. Intravenous infusions of nitric oxide synthase inhibitors, Nω-nitro-l-arginine-methyl ester (l-NAME) and Nω-nitro-l-arginine, induced clusters of duodenal contractions like phase III of migrating motor complexes and simultaneously inhibited flow rate, bicarbonate ion and enzyme outputs of pancreatic juice. The effects of l-NAME were inhibited by simultaneous infusion of l-arginine, but not altered by adrenergic blockade using a combined infusion of phentolamine and propranolol. Inhibition of the pancreatic secretion occurred in coincidence with initiation of the duodenal contractions, while the pancreatic secretion was not inhibited when the premature duodenal contractions were abolished by the l-arginine infusion. The initiation of the cluster of duodenal contractions by l-NAME was not abolished by background infusion of atropine, whereas the amplitude of contractions was significantly inhibited by atropine. These results suggest that intrinsic nitric oxide plays a crucial role in the regulation of duodenal tone and maintenance of continuous secretion by the exocrine pancreas in sheep. These results also implied that inhibition of pancreatic exocrine secretion by the nitric oxide synthase inhibitor is presumably mediated in part through the contractile effect on the duodenum. Accepted: 27 June 2000     

Rational sequence of tests for pancreatic function.

Of 144 patients with suspected pancreatic disease in whom a 75Se-selenomethionine scan was performed, endoscopic retrograde pancreatography (ERP) was successful in 108 (75%). The final diagnosis is known in 100 patients and has been compared with scan and ERP findings. A normal scan reliably indicated a normal pancreas, but the scan was falsely abnormal in 30%. ERP distinguished between carcinoma and chronic pancreatitis in 84% of cases but was falsely normal in five patients with pancreatic disease. In extrahepatic biliary disease both tests tended to give falsely abnormal results. A sequence of tests to provide a rapid and reliable assessment of pancreatic function should be a radio-isotope scan, followed by ERP if the results of the scan are abnormal, and a Lundh test if the scan is abnormal but the findings on ERP are normal.     

Exocrine pancreatic carcinogenesis and autotaxin expression

Exocrine pancreatic cancer is an aggressive disease with an exceptionally high mortality rate. Genetic analysis suggests a causative role for environmental factors, but consistent epidemiological support is scarce and no biomarkers for monitoring the effects of chemical pancreatic carcinogens are available. With the objective to identify common traits for chemicals inducing pancreatic tumors we studied the National Toxicology Program (NTP) bioassay database. We found that male rats were affected more often than female rats and identified eight chemicals that induced exocrine pancreatic tumors in males only. For a hypothesis generating process we used a text mining tool to analyse published literature for suggested mode of actions (MOA). The resulting MOA analysis suggested inflammatory responses as common feature. In cell studies we found that all the chemicals increased protein levels of the inflammatory protein autotaxin (ATX) in Panc-1, MIA PaCa-2 or Capan-2 cells. Induction of MMP-9 and increased invasive migration were also frequent effects, consistent with ATX activation. Testosterone has previously been implicated in pancreatic carcinogenesis and we found that it increased ATX levels. Our data show that ATX is a target for chemicals inducing pancreatic tumors in rats. Several lines of evidence implicate ATX and its product lysophosphatidic acid in human pancreatic cancer. Mechanisms of action may include stimulated invasive growth and metastasis. ATX may interact with hormones or onco- or suppressor-genes often deregulated in exocrine pancreatic cancer. Our data suggest that ATX is a target for chemicals promoting pancreatic tumor development.     

Clinical value of serum immunoreactive trypsin concentration.

The clinical value of estimation of serum concentrations of immunoreactive trypsin was evaluated by studying 46 healthy controls, 23 controls in hospital, 44 patients with chronic pancreatic disease, and 184 patients with non-pancreatic conditions in which pancreatic disease commonly enters into the differential diagnosis. Serum trypsin concentration had a log normal distribution in the controls, and the calculated normal range was considerably wider than that previously reported. The concentration was abnormal in only 13 out of 27 patients with chronic pancreatitis and was extremely variable in patients with pancreatic cancer. Abnormal results occurred in 11% of the patients with non-pancreatic disease. Eighteen patients had a subnormal trypsin concentration, of whom six did not have pancreatic disease and 12 had either chronic pancreatitis or pancreatic cancer. There was no correlation between serum trypsin concentration and mean tryptic activity as measured by the Lundh test. Of 11 patients with pancreatic steatorrhoea, only seven had subnormal trypsin concentrations. There results suggest that the serum concentrations of immunoreactive trypsin has a low specificity and sensitivity for pancreatic disease and does no reflect the degree exocrine insufficiency in patients with proved chronic pancreatitis.     

Antroduodenal motility in chronic pancreatitis: are abnormalities related to exocrine insufficiency?

In patients with chronic pancreatitis (CP) the relation among exocrine pancreatic secretion, gastrointestinal hormone release, and motility is disturbed. We studied digestive and interdigestive antroduodenal motility and postprandial gut hormone release in 26 patients with CP. Fifteen of these patients had pancreatic insufficiency (PI) established by urinary para-aminobenzoic acid test and fecal fat excretion. Antroduodenal motility was recorded after ingestion of a mixed liquid meal. The effect of pancreatic enzyme supplementation was studied in 8 of the 15 CP patients with PI. The duration of the postprandial antroduodenal motor pattern was significantly (P < 0.01) prolonged in CP patients (324 +/- 20 min) compared with controls (215 +/- 19 min). Antral motility indexes in the first hour after meal ingestion were significantly reduced in CP patients. The interdigestive migrating motor complex cycle length was significantly (P < 0.01) shorter in CP patients (90 +/- 8 min) compared with controls (129 +/- 8 min). These abnormalities were more pronounced in CP patients with exocrine PI. After supplementation of pancreatic enzymes, these alterations in motility reverted toward normal. Digestive and interdigestive antroduodenal motility are abnormal in patients with CP but significantly different from controls only in those with exocrine PI. These abnormalities in antroduodenal motility in CP are related to maldigestion.     

Physiological Activity of Peptides Isolated from Human Gastric and Duodenal Ulcerous Tissues

Some drug formulations containing digestive enzymes were shown to stimulate gastric and duodenal secretion owing to low-molecular-weight peptides (LMWPs) generated during isolation of the enzymes from raw biological materials. Similar LMWPs were found in gastric and duodenal ulcerous tissues. It was concluded that, transferred with the blood and the lymph, the LMWPs produced in such tissues continuously stimulate the exocrine function of the pancreas (probably, through a system of immunoreceptors). Persistent pancreatic hypersecretion results in functional failure of the gland and in chronic pancreatitis.     

Intermediate cells in the adult human pancreas. Contribution to the transformation of differentiated cells in vertebrates

Problems associated with the transformation of differentiated cells in vertebrate organisms are discussed based on electron microscopical results of intermediate cells (i.e. cells with morphological characteristics of exocrine acinar cells and endocrine cells of Langerhans' islets) in the pancreas of human adults with chronic insulin-dependent diabetes mellitus. In this context, reference is made to experimental results of Scarpelli, Rao, and coworkers relating to the occurrence of hepatocyte-like cells in the pancreas of Syrian golden hamsters (Rao and Scarpelli 1980; Scarpelli and Rao 1981; Rao et al. 1983). These observations show that exocrine acinar cells of the pancreas may, even beyond the neonatal period, become transformed, depending upon different triggering stimuli, into different endocrine islet cells, or into hepatocytes, this being accomplished either directly or by new formation of cells (regeneration) with abnormal differentiation (metaplasia). Obviously, transformation is effected through a change in the activation of gene loci: the normally stably blocked genes are partially or completely deblocked for the functions of different endocrine islets cells or hepatocytes, and the original genetic expression of exocrine pancreatic functions is blocked either partially or completely. The results presented and quoted in this paper suggest that in all differentiated cells derived from the endoderm of the foregut, such as duct cells, exocrine and endocrine pancreatic cells, and hepatocytes, functional programs are retained which can be modified in the manner quoted to enable partial or complete transformation into one or another of these differentiated cells in the adult organism.