Effects of micronutrient status on oxidative stress and exocrine pancreatic function in patients with chronic pancreatitis.

Micronutrient deficiency and oxidative stress in relation to pancreatic exocrine insufficiency among chronic pancreatitis (CP) patients needs closer scrutiny. In this study, we examined the role of micronutrients (Zn and Cu) on oxidative stress related parameters and stool elastase-1 in tropical chronic pancreatitis (TCP) and alcoholic chronic pancreatitis (ACP) patients. We also compared oxidative stress parameters in CP patients with low and normal pancreatic stool elastase-1, estimation of which is the best available test for detecting pancreatic exocrine insufficiency. Ninety-one (56 male and 35 female) TCP cases, 84 ACP cases and 113 (60 male and 24 female) healthy controls were studied. Levels of reduced glutathione (GSH), ascorbic acid and zinc and activities of glutathione peroxidase (GPx), superoxide dismutase (SOD) reduced significantly, while thiobarbituric acid reactive substance (TBARS) and copper level increased significantly in erythrocytes of both ACP and TCP patients in comparison to healthy controls. However, we did not find differences in these parameters between diabetic and non-diabetic TCP patients or between diabetic and non-diabetic ACP patients. The study suggested an association between pancreatic exocrine insufficiency and oxidative parameters, while zinc deficiency was found to be correlated with SOD and pancreatic exocrine insufficiency in CP, irrespective of its etiology.

Insuficiência exócrina do pâncreas: etiologias / Exocrine pancreatic insufficiency: etiology

Insuficiência exócrina do pâncreas tem sido revisitada em vários compêndios médicos internacionais e suas novas etiologias avaliadas e reconfirmadas. Neste artigo abordamos as causas mais comuns e tradicionais, pancreatite crônica e fibrose cística, bem como as recentemente mais enfatizadas como doença celíaca e diabetes mellitus. Comentamos a clínica e o diagnóstico precoce e o tratamento com reposição enzimática

Pancreatic exocrine insufficiency has been broadly discussed in international medical literature. New aetiologies have been studied and reaffirmed. In this paper we describe common and traditional causes such as chronic pancreatitis and cystic fibrosis as well as the most recently emphasised celiac disease and diabetes. We also review clinical features, early diagnosis and pancreatic enzyme replacement therapy

Morphological and functional outcome after pancreatic necrosectomy and lesser sac lavage for necrotizing pancreatitis.

BACKGROUND: Immediate outcomes after pancreatic necrosectomy have improved in recent years. This study reviews our short-term to medium-term experience of structural and functional changes in the pancreas after necrosectomy. METHODS: Ten patients (8 males, median age 35 years), discharged after pancreatic necrosectomy for acute necrotizing pancreatitis between 1996 and 1998 were reviewed after a median period of 22 months. Clinical evidence of pancreatic dysfunction was documented at follow-up interview. Patients underwent computed tomography of the abdomen, endoscopic retrograde pancreatography, oral glucose tolerance test, fecal fat estimation and fasting serum C-peptide estimation (CPE). RESULTS: No patient had repeat episodes of pancreatitis during the follow-up period. Three patients developed de-novo diabetes after discharge. No patient had symptoms of steatorrhea. Five patients showed severe changes on CECT. ERCP showed marked changes in six patients, the commonest being an abrupt cut-off of the main pancreatic duct. Glucose tolerance was abnormal in three patients and impaired in two patients while fecal fat excretion was abnormal in 8 patients. CONCLUSIONS: Severe acute pancreatitis and necrosectomy are associated with significant structural and functional changes on medium-term follow-up.

Study of pancreatic islet cell function in cirrhotic patients due to hepatitis C virus

The liver is of key importance in the proper functioning of most of endocrine system. It is a major organ for metabolic degradation of many hormones. In chronic liver disease, there is a change in the concentrations of main pancreatic hormones. In this study, we aimed to study pancreatic islet cell hormones in non ascitic non diabetic cirrhotic HCV patients by measuring these hormones basally and after intravenous glucose load with different concentrations to evaluate pattern of endocrine pancreatic hormonal response at increasing glucose concentration. This case-control study included 25 non ascitic non diabetic patients with cirrhosis due to HCV infection; age ranged from 28 to 60 years. They were selected from outpatient clinic of National Hepatology and Tropical Medicine Research Institute [NHTMRI] during June 2004 to January 2005. Fifteen age and sex matched apparently healthy control subjects from same area were also included in study. Assessment of pancreatic islet cell function was done by assaying insulin, C-peptide, somatostatin and glucagon hormones. All hormones were determined by radioimmunoassay [RIA] for both patients and controls. Basal insulin, basal somatostatin and basal glucagons levels were significantly higher than that of controls [p<0.05]. Basal C-peptide was significantly lower than that of controls [p<0.05]. After intravenous glucose load with different concentrations 5%, 10% and 25%, insulin level showed a significant increase than controls [p<0.05], while other hormones showed no significant difference as compared to controls [p>0.05]. Pancreatic islet cell functional defects with liver cirrhosis due to HCV infection

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal / Pancreatic exocrine function in diabetes mellitus: Determination of fecal elastase

Background: One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. Aim: To study pancreatic exocrine function in diabetics patients. Material and methods: Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. Results: Mean age was 60±12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 µg/g) in 47 (67%) patients, mildly decreased (100-200 µg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy or with insulin requirement. Conclusions: One third of this group of diabetic patients had decreased levels of fecal elastase, that was associated with the time of evolution of diabetes. Patients with lower levels of elastase have significantly more steatorrhea. Among diabetics it is possible to find a group of patients with non diagnosed chronic pancreatitis.

Study of pancreatic islet cell function in cirrhotic patients due to hepatitis C virus

The liver is of key importance in the proper functioning of most of the endocrine system. It is a major organ for metabolic degradation of many hormones. In chronic liver disease, there is a change in the concentrations of the main pancreatic hormones. Is to study the pancreatic islet cell secretory function of insulin, C-peptide, somatostatin and glucagon hormones in non ascitic non diabetic cirrhotic HCV patients by measuring these hormones basally and after intravenous glucose load with different concentrations at several intervals in order to evaluate the pattern of endocrine pancreatic hormonal response at increasing glucose concentration. The case-control study included 25 non ascitic non diabetic patients with cirrhosis due to HCV infection; their ages ranged from 28 to 60 years. They were selected from outpatient clinic of the National Hepatology and Tropical Medicine Research Institute [NHTMRI] in the period from June 2004 to January 2005. Fifteen age and sex matched apparently healthy control subjects from the same area were also included in the study. Assessment of pancreatic islet cell function was done by assaying insulin, C-peptide, somatostatin and glucagon hormones. All hormones were determined by radioimmunoassay [RIA] for both patients and controls. Basal serum insulin, basal plasma somatostatin and basal plasma glucagon levels were significantly higher than that of the control group [p<0.05], while basal serum C-peptide was significantly lower than that of the control group [p<0.05]. After intravenous glucose load with the different concentrations 5%, 10% and 25%, serum insulin level showed a significant increase than that of the controls [p<0.05]. while other hormones showed no significant difference as compared to the control group [p>0.05]. The study suggests pancreatic islet cell functional defects with liver cirrhosis due to HCV infection

Natural course of asymptomatic pancreatic pseudocyst: a prospective study.

AIM: To study the natural course of asymptomatic pseudocysts of the pancreas. METHODS: Thirty patients (age range 18-68 years, mean 44; 24 men) with asymptomatic pseudocysts of the pancreas were enrolled between December 2001 and December 2003, and were followed up every month. Those who developed symptoms due to pseudocyst (increasing pain or features of obstruction such as vomiting or jaundice) were subjected to an endoscopic or surgical drainage procedure. End point of the study was either spontaneous resolution of pseudocyst or drainage procedure. RESULTS: Eighteen (60%) of 30 patients had resolution of the pseudocyst over an average duration of 5 months. Maximum diameter of less than 7.5 cm and cyst volume less than 250 mL were significantly more frequent in patients with resolution of pseudocyst than in those without (14/18 vs 2/12 [p=0.001] and 15/18 vs 2/12 [p=0.0003], respectively). Presence of internal debris was associated with non-resolution (9/12 vs 2/18; p=0.001). CONCLUSION: Pseudocysts with less than 7.5 cm diameter, volume less than 250 mL, and absence of internal debris were associated with spontaneous resolution within an average duration of 5 months.

A randomized trial of oral refeeding compared with jejunal tube refeeding in acute pancreatitis.

BACKGROUND: Relapse of pain during refeeding in acute pancreatitis may have a relation to the route of refeeding. AIM: To compare the efficacy of oral refeeding with jejunal tube refeeding in patients with acute pancreatitis, and determine the frequency of refeeding pain and factors associated with it. METHODS: Consecutive patients with acute pancreatitis, severe enough to stop oral feeding for 48 hours, were randomized to receive either oral or jejunal tube refeeding. The feeds were similar in calorie, lipid and protein content (400 Kcal on day 1, 1000 Kcal on day 2, 1400 Kcal on day 3, 1500 Kcal on day 4, and 1700 Kcal on day 5). Clinical and biological factors (serum amylase, lipase, C-reactive protein) and Balthazar CT severity index were recorded. Frequency of pain relapse and factors associated with it were analyzed. RESULTS: 28 patients with acute pancreatitis (biliary 14, alcohol 9, idiopathic 3, post-ERCP 2) were included. Fifteen patients received oral and 13 received enteral tube refeeding. Four patients in the oral group and none in the enteral tube group had relapse of pain (p=0.06). The factors associated with refeeding pain were longer duration of initial pain (p<0.02) and higher CT severity index (p<0.02). Pain relapse increased the total hospital stay (p<0.004) and hospital stay after the first attempt at feeding (p<0.001). CONCLUSIONS: Jejunal tube refeeding may reduce the frequency of pain relapse as compared to oral refeeding although the difference was not significant in this study. Longer duration of pain and higher CT severity index score were associated with occurrence of refeeding pain.

The Clinical Usefulness of Fecal Elastase-1 Test as an Exocrine Pancreatic Function Test for the Diagnosis of Chronic Pancreatitis / 대한소화기내시경학회지

BACKGROUND/AIMS: The quantitative analysis of fecal elastase-1 has been proposed as a noninvasive test for the examination of pancreatic exocrine function. Therefore, we evaluated the diagnostic value of fecal elastase-1 by comparing with endoscopic intraductal secretin test (IDST) which is used as a direct exocrine function test for the diagnosis of chronic pancreatitis. METHODS: Fecal elastase-1 concentrations were measured by ELISA in spot stool samples of 40 healthy control subjects, 21 patients with liver disease, and 12 patients with chronic pancreatitis diagnosed with endoscopic retrograde cholangiopancreatography (ERCP) and IDST. Chronic pancreatitis were then sub-classified into mild (I), moderate (II) and severe form (III), using the Cambridge classification according to ERCP finding. The linear regression analysis to evaluate the correlation between the concentration of fecal elastase-1 and IDST was performed during ERCP. The cut-off value of fecal elastase-1 to discriminate chronic pancreatitis was calculated based on receiver operating characteristic curve, and the clinical usefulness of fecal elastase-1 in the diagnosis of chronic pancreatitis was evaluated. RESULTS: There were several significant correlations between fecal elastase-1 and various parameters of IDST: pancreatic juice secretory volume (r=0.797, p<0.002), bicarbonate concentration (r=0.846, p<0.001), elastase-1 concentration in pancreatic juice (r=0.671, p<0.017), and amylase output (r=0.783, p<0.003). The mean value of fecal elastase-1 concentration in the patients with chronic pancreatitis (197+/-77microgram/g stool) was significantly lower than those in the healthy control subjects (815+/-133microgram/g stool) and patients with liver disease (594+/-206microgram/g stool) (p<0.05). The cutoff value of fecal elastase-1 to discriminate between the healthy control and chronic pancreatitis patients was 201microgram/g stool. With this cutoff value, the accuracy, sensitivity, and specificity of fecal elastase-1 to diagnose chronic pancreatitis were 78.8%, 67.7%, and 82.5%, respectively, compared to the morphological severity (the sensitivity of mild, moderate, and severe chronic pancreatitis was 33.3%, 66.7%, 83.3%, respectively). CONCLUSIONS: Measurement of fecal elastase-1 is a reliable and sensitive non-invasive test for the diagnosis of moderate to severe forms of chronic pancreatitis.

A Large Malignant Insulinoma: Case Report with Endosonographic, Immunohistochemical and Ultrastructural Features

Malignant insulinoma in the beta cells of the pancreatic islet is rare and usually presented as hypoglycemia. We report a case of large malignant insulinoma in a 53-year-old Korean woman. A presumptive clinical diagnosis was made before surgery, based on the high plasma insulin-to-glucose ratio and a large solitary heterogeneous pancreatic mass by abdominal computed tomography and endosonography. The tumor measured 5.8X4.7X4.5 cm in dimension and showed capsular invasions and metastases in two of four peripancreatic lymph nodes. The tumor cells were strongly immunoreactive to insulin and had a high Ki-67 labeling index (13%) and atypical membranous electron-dense granules, ranging from 120 to 400 nm in diameter, in the cytoplasm on electron microscopy. The patient was treated by distal pancreatectomy with splenectomy and rapidly recovered without neurohypoglycemic symptoms. This case showed not only lymph node metastases, the most reliable parameter for malignancy in pancreatic endocrine tumors, but also other valid diagnostic clues, such as high Ki-67 labeling index, heterogeneous enodosonographic findings, capsular invasions with large tumor and pure atypical secretory granules.

Pancreatitis

Pancreatic inflammatory disease may be classified as acute pancreatitis(AP) and chronic pancreatitis(CP) by primarily clinical criteria, with the obvious difference between them being restoration of normal function in the former and permanent residual damage in the latter. Gallstones and alcohol are the most common causes of acute pancreatitis. Abdominal pain is the major symptom. The diagnosis of AP is usually established by the presence of an increased serum amylase and lipase. CT scanning is the imaging method of choice in determining the severity and complications of AP. There are no generally recognized specific treatments for AP. Supportive therapy, which includes vigorous intravenous hydration, ample analgesia, and vascular, respiratory, and renal support as needed, remains the mainstay of therapy. CP may present as episodes of acute inflammation superimposed on a previously injured pancreas or as chronic fibrotic damage with persistent pain or malabsorption. Alcoholism is the most common cause of CP. The classic triad of pancreatic calcification, steatorrhea, and diabetes mellitus usually establishes the diagnosis of CP. ERCP and pancreatic function test are gold standard imaging procedures for diagnosing CP and planning treatment. Therapy for patients with CP is directed toward major problems such as pain, malabsorption, and diabetes mellitus. Pancreatic enzyme replacement therapy improves the abdominal pain and malabsorption. If Complications is found, endoscopic or Surgical treatments should be considered.

Evaluation of safety and efficacy of a gold containing Ayurvedic drug.

Gold containing Ayurvedic preparation, Swarna Vasant Malti, was given to 20 male persons in a dose of 100 mg twice a day for 40 days under supervision of Ayurvedic physicians. The total cumulative intake of 160 mg of gold at the rate of 4 mg per day in this form did not have any toxic effect on human body as evidenced by clinical examination, unaltered body weight, absence of urinary pathology and by 30 sensitive biochemical and enzymatic tests. The gold from this Ayurvedic preparation was found in plasma and erythrocytes, excreted partly in urine and was present in semen. Gold binding to albumin and hemoglobin slightly increased their electrophoretic mobility towards anode. This gold preparation seemed to increase sperm motility and prostatic activity.

Avaliaçäo hematológica e bioquímica dos cäes da raça beagle / Hematological and biochemical evaluation of beagle dogs

O objetivo deste trabalho é determinar um padräo de valores bioquímicos que sirvam de referência para o hemograma e para as provas de funçäo hepática, renal e pancreática para cäes Beagle utilizados em pesquisa. As amostras de sangue foram coletadas de machos e fêneas, saudáveis, entre 1 e 2 anos de idade. foram realizados os exames: a)Hemograma - hematócrito, hemoglobina, leucócitos, segmentados, bastöes, linfócitos, monócitos, eosinófilos, plaquetas; b)Funçäo Hepática - TGO, TGP, fosfatase alcalina, LDH, colesterol total, bilirrubinas direta e total; c)Funçäo Renal - creatina, uréia; d)Funçäo Pancreática - amilase, lipase, proteína C reativa insulina, glicemia, hemoglobina glicosilada. Sugerimos que os valores do hemograma e das provas de funçäo hepática, renal e pancreática obtidas sejam utilizados como valores de referência para cäes da raça Beagle utilizados em pesquisa

Elastasa 1: un nuevo test de función pancreática / Elastase 1: a new test of pancreatic function

Se da cuenta de un nuevo test de función pancreática exocrina, consistente en la determinación de elastasa 1 en las heces. Este examen tiene mayor sensibilidad y especificidad de los utilizados hasta ahora. La determinación de elastasa 1 en sangre tiene un valor similar a la de amilasa y lipasa, pero su utilidad diagnóstica es más persistente y no tiene resultados falsos positivos derivados de fuentes extrapancreáticas, como ocurre con la amilasa

Usefulness of Intraductal Secretin Test in Assessing Exocrine Pancreatic Function in Patients with Chronic Pancreatitis / 대한소화기내시경학회지

BACKGROUND/AIMS: The duodenal intubation test (duodenal secretin test; DST) is now considered the 'gold standard' test of exocrine pancreatic function in detecting exocrine pancreatic dysfunction in patients with chronic pancreatitis. However, the DST has not been widely used, because it is time-consuming, invasive, and labor-intensive. On the other hand, intraductal secretin test (IDST) with endoscopic retrograde cannulation of the main pancreatic duct has been showed similar diagnostic efficiency compared with DST. We assessed the clinical usefulness of IDST and investigated parameters for assessing impaired pancreatic function of IDST. METHODS: Pure pancreatic juices were collected from 12 patients with chronic pancreatitis by endoscopic cannulation after a bolus intravenous injection of secretin 100 U, for 15min in three 5-min intervals. Five parameters of IDST were measured, and the sensitivity, specificity, and accuracy of IDST evaluated compared with ERP. RESULTS: When we regarded mean-1.5 SD as the lower limits of IDST, the diagnostic sensitivity, specificity, and accuracy of five parameters to detect chronic pancreatitis were 91.7-100%, 75-87.5%, and 85-90%, respectively. Among five parameters, pancreatic juice secretory volume, bicarbonate concentration, and amylase output showed the highest diagnostic accuracy, followed by lipase output and bicarbonate output. A 10-min collection showed as much information as a 15-min collection. CONCLUSIONS: 10-min intraductal secretin test is useful as the conventional exocrine pancreatic function test in detecting exocrine pancreatic dysfunction in patients with chronic pancreatitis and the most discriminatory parameters are pancreatic juice secretory volume, bicarbonate concentration, and amylase output.

Pancreatic insufficiency in giardiasis

To study pathological mucosal changes, gut bacteriological spectrum [bacterial overgrowth] and some pancreatic exocrine function in Giardiasis. 50 Patients having Giardia lamblia infection proved by stool examination beside, 20 healthy controls of matched age, sex and socioeconomic status. All patients and controls were subjected to thorough history and clinical examinations. Stool examination for diagnosis of giardia and study of fat contents, liver function tests, renal function tests, glucose tolerance curve, plain x-ray abdomen and abdominal ultrasonographly. Pancreatic function tests in the form of trypsin and amylase activities in duodenal aspirate, besides serum amylase and trypsin concentrations Upper GIT endoscopy for taking duodenal biopsy Also, parsitological and bacteriological examination for the duodenal aspirates. Both amylase and trypsin activities were lowered in patients than controls [t = 9.256] [t =7.284] and in patients with severe mucosal abnormalities than in patients with minor or no abnormalities [t = 7.462] and [t = 6.567] respectively. On the other hand, both serum amylase and trypsin concentrations showed significant elevation in patients than controls [t = 8.676] and [t= 7.827] and in patients with severe mucosal abnormalities than in patients with minor or no abnormalities [t =7.541] and [t = 7.623] respectively Giardia infection leads to a state of pancreatic exocrine insufficiency which resulted mainly from duodenal mucosal changes rather than bacterial overgrowth