Value of the P3 amylase fraction as an indicator of the long-term prognosis of acute pancreatitis.

The value of the serum P3 amylase fraction in the prediction of the course of acute pancreatitis (AP) after the initial episode was studied prospectively. Eighty-eight patients with AP were included. Amylase, lipase, trypsin and the P3 amylase fraction were measured in serum obtained at the time of discharge. Patients were followed for 60 days after discharge and divided into two groups: 75 patients who did not have complications, of whom 22.6 per cent displayed elevation of one or more pancreatic enzymes at discharge (17.3 per cent hypertrypsinaemia, 9.3 per cent hyperlipasaemia and 6.6 per cent P3 fraction); and 13 patients who had an unsatisfactory outcome (4 died, 4 developed a pseudocyst and 5 presented with recurrent pancreatitis). All of the latter group had an increase in at least one enzyme at the time of discharge (92.3 per cent P3 fraction, 69.2 per cent trypsin, 15.3 per cent lipase, and 7.6 per cent amylase). Both the persistence of the P3 fraction and hypertrypsinaemia were significantly more frequent in patients with an unfavourable outcome than in those with an uncomplicated course (P less than 0.001). On the other hand, persistent elevation of total amylase and lipase were unrelated to outcome. The hospitalization time was similar in both groups (good outcome 21.4 +/- 1.9 days, unfavourable outcome 17.3 +/- 5.3 days). It is concluded that the presence of P3 amylase fraction or hypertrypsinaemia at the time of discharge from hospital in a patient with acute pancreatitis suggests a risk of a later complication. Careful surveillance until enzyme levels become normal is urged. It is suggested that isoamylase P3 determination is the most sensitive assay to screen for the complications of acute pancreatitis.

Reversibility of exocrine pancreatic failure in chronic pancreatitis.

In patients with chronic pancreatitis, the development of exocrine pancreatic failure is generally thought to be an irreversible process. We found evidence to the contrary in a prospective study of 70 patients who were evaluated by endoscopic retrograde cholangiopancreatography and sequential measurements of stool fat, percent urinary PABA excretion, and serum trypsin during a follow-up time period of 1-4 yr. Initial p-aminobenzoic acid (PABA) testing showed exocrine failure in 51 patients, 35 of whom had low serum trypsin levels while 14 (27%) disclosed unexpectedly high trypsin concentrations. Ductal morphology was similar in patients with low and high trypsin values. In 8 of the latter cases, steatorrhea improved and pancreatic function tests became normal after pancreaticojejunostomy in 4 patients, alcohol abstinence in 3 patients, and spontaneous resolution of a pseudocyst in 1 patient. Pancreatic cancer was present in a further 3 patients. Of the 37 patients with low PABA and low trypsin at the outset, there was no improvement of exocrine function in 17 of 18 who were surgically treated. Conservative treatment had a similar effect in another 6 patients who were available for follow-up in this group. The mean duration of symptomatic disease was shorter (p less than 0.001) in patients with low PABA and high trypsin levels (1.4 +/- 1.2 yr) than in those with low PABA and low trypsin levels (4.5 +/- 1.3 yr). The results show that up to 20% of patients with chronic pancreatitis have exocrine pancreatic failure, which is apparently due to early ductal obstruction of a gland with preserved function; this situation can be suspected when low urinary PABA excretion and high serum trypsin levels are simultaneously found; and (c) exocrine failure may be reversible in these patients by using a pancreatic drainage procedure or alcohol abstinence. Such a peculiar pattern of pancreatic function tests may also suggest pancreatic cancer.

Comparison of fasting, nasogastric suction and cimetidine in the treatment of acute pancreatitis.

88 unselected patients with acute pancreatitis entered a randomized clinical trial comparing the therapeutic efficacy of fasting alone, nasogastric suction and fasting plus cimetidine. The disease was mild to moderate in all but 3 cases, and cholelithiasis was the main etiological factor. The number of treatment failures and complications, and the clinical outcome were similar in the three groups. However, when compared to fasting alone, nasogastric suction was shown to delay the resumption of bowel activity a mean of 11 h (p less than 0.05), prolong the duration of pain a mean of 20 h (p less than 0.01), increase analgesic needs (pentazocine lactate) a mean of 64 mg (p less than 0.05), and lengthen hospital stay a mean of 2 days (p = NS). In conclusion, cimetidine has no beneficial effects in acute pancreatitis. It is suggested that fasting alone be initially used as the simpler, safer and more economical therapy. Nasogastric suction should be reserved for patients presenting with intestinal ileus, a situation that occurred in 1 out of every 8 cases in the present series.