[Specificities of the diagnostics and therapy of exocrine pancreatic insufficiency]. / Zvlástnosti diagnostiky a terapie exokrinní pankreatické nedostatecnosti

Exocrine pancreatic insufficiency develops steadily; however, the initial reduction in secretion is practically not diagnosable. More advanced stages, which usually replicate morphological changes, can be determined with tests which asses the exocrine pancreatic capacity. Substantial damage of the pancreas and replacement of viable parenchyma with connective tissue is accompanied by the occurrence of steatorrhoea. This corresponds to a reduction in exocrine pancreatic secretion below 10% of physiological secretion. Exocrine pancreatic secretion tests are still not sufficiently sensitive for diagnosing early stages of pancreas defects and thus are not suitable for diagnostics. Furthermore, detecting reduced exocrine secretion does not provide any information about the aetiology of the disease, e.g. inflammation/tumor. The most precise test is a costly examination, including a stimulation of the gland with enterohormones; however, breath tests are usually recommended for the assessment of exocrine insufficiency therapy. Exocrine pancreatic insufficiency therapy consists of administering drugs containing pancreatin (amylase, lipase, and peptidase) to patients diagnosed with steatorrhoea, manifest pancreatic insufficiency. As standard, capsules containing microparticles of 1-2mm are recommended. They have a protective coating that prevents inactivation in the microparticles of the contained enzymes by gastric hydrochloric acid. The drug should be administered during each meal, i.e. several times a day. The most common mistake during pancreatic enzyme therapy is under dosage. The following rule applies to patients with digestive insufficiency: 40,000-50,000 UNT of lipase are to be administered during "main meals" and 25,000 UNT of lipase during morning or afternoon snacks. The drug should be taken during the meal; insufficient treatment and dosage are associated with insufficient digestion and absorption ofa number of substances and also with pancreatic malabsorption.

Monitoring of daily gliadin intake in patients on gluten-free diets.

The aim of the study was to show patients suffering from the coeliac disease, their real gliadin daily intake, offer them very useful information concerning their diet and to find random possible mistakes. The monitoring was carried out within the context of their routine everyday diet regimen. The daily intake of gliadin in the diet was quantified on the basis of gliadin determination in their current daily food. The gluten-free diet was followed for 30 days. The patients were taking regular daily meals, drinks, and sometimes medicines or food supplements. The patients were provided with instructions, survey forms, digital scales, polyethylen bottles and sacks. The patients took out the stipulated amount, which served as a sample of each of their daily meals. The samples included both homemade meals as well as commercial products. The content of gliadin in daily meal was determined by the sandwich ELISA method. The daily gliadin intake was calculated on the base of the reported amount of meals ingested. 1,900 food samples were analyzed within the framework of this study. Several contaminated commercial foods were found; nevertheless this fact did not influence the otherwise satisfactory overall picture of the daily gliadin intake by the patients followed. The results in 14 patients revealed a satisfactory adherence to the gluten-free diet. It was proved that conscientiousness and awareness on the part of coeliac patients, or those taking care of them, is of paramount importance in determining the choice of foods comprising a gluten-free diet.

[Hyperamylasemia, laboratory and clinical aspects]. / Hyperamylazémie, laboratorní a klinické aspekty.

Biochemical estimation of the total a-amylase represents in the Czech Republic almost two millions of assessments per year. Estimation of the total alpha-amylase for the diagnostics of pancreatic diseases has a very low specificity and it is therefore recommended to analyze specific pancreatic enzymes - pancreatic isoenzyme alpha-amylase and pancreatic lipase. Paper summarizes laboratory and clinical aspects aimed namely on hyperamylasamia.

[Faecal elastase I--its use in diagnosis of chronic pancreatitis]. / Stanovení elastázy I ve stolici--vyuzití v diagnostice chronické pankreatitidy.

BACKGROUND: The diagnosis of chronic pancreatitis is based on the imaging methods. These imaging methods show the main morphological changes in the pancreatic ducts and its parenchyma, but they do not define the function of the pancreas. The aim of our study was Faecal Elastase I. determination in patients with chronic pancreatitis. The test is a simple, non-invasive method of the investigation of the pancreatic exocrine insufficiency. The Faecal Elastase I occurring in the stool was correlated with the level of the damage of pancreatic tissue together with the control group of the patients with different diagnoses. METHODS AND RESULTS: Faecal Elastase I (mean values in ug/g of stool) detection is a simple, non-invasive method which correlates well with the damage of pancreatic tissue, stemming from chronic pancreatitis. This test is routinely used especially in the diagnosis of chronic pancreatitis. The classification of chronic pancreatitis currently depends on the morphological changes of the pancreatic duct system (the patho-morphological changes). We are currently missing the classification describing simultaneously the morphological changes of the gland and the function of the pancreas. In our studies we have used a newly proposed classification system, which was put together in Bern, 2000 (1). This new system encompasses morphological and functional changes. Faecal Elastase I was determined by a microplate ELISA method using monoclonal antibody to human pancreatic protein. The Faecal Elastase I. was tested in the stool of the 196 patients with chronic pancreatitis stemming from alcoholism. The occurrence of Faecal Elastase I. was classified according to the levels assigned by the classification system. The control group used in this study included 144 patients with different diagnoses. The results demonstrate a very good correlation of Faecal Elastase I. with the grading of the newly proposed classification system of chronic pancreatitis. Patients with the highest levels of the damage of the pancreas had a significantly lower occurrence of Faecal Elastase I. in comparison with the non-pancreatic control group and in patients with chronic pancreatitis who had no clinical complications or damage of endocrine and exocrine functions of the pancreas. CONCLUSIONS: Feacal Elastase I performance plays an important role in diagnosing of the severe cases of chronic pancreatitis and in the follow-up of the chronic pancreatitis in the patients with the intermediate damage of the pancreas.

IgA and IgG antigliadin, IgA anti-tissue transglutaminase and antiendomysial antibodies in patients with autoimmune thyroid diseases and their relationship to thyroidal replacement therapy.

Celiac disease is a chronic illness of the small bowel caused by gliadin intolerance in genetically predisposed subjects. The aim of this study was to investigate serum levels of IgA and IgG antigliadin antibodies, IgA antiendomysial antibodies, and IgA anti-tissue transglutaminase antibodies in 169 patients with autoimmune thyroid diseases, i.e. chronic thyroiditis and Graves' disease. Antiendomysial antibodies were positive in 2 out of 169 persons (1.18%), IgA antigliadin antibodies in 15.98%, IgG antigliadin antibodies in 51.48%, and IgA anti-tissue transglutaminase in 14.79%. The prevalence of positivity was higher compared to the 1312 control blood donors described in our previous study (Vancíková et al. 2002) (p<0.05). Patients with chronic thyroiditis treated with a high replacement dosage of levothyroxin (125-200 microg daily) had higher serum levels of IgA antigliadin antibodies in comparison with patients treated with a lower dosage (50-100 microg daily) (medians: 13.00 vs. 19.69, p=0.033). We found a negative correlation of IgA anti-tissue transglutaminase antibodies and total calcium serum levels (r = -0.480, p=0.0236, n=22). We can conclude that in persons with autoimmune thyropathy there is a high prevalence of positive antigliadin, anti-tissue transglutaminase and antiendomysial antibodies. Latent celiac disease may lead to impaired resorption of therapeutically administered levothyroxine, calcium, or other substances.

[Occult fecal blood loss--comparison of immunochemical and biochemical tests]. / Okultní krvácení ve stolici--srovnání imunochemického a biochemického testu stanovení.

BACKGROUND: Test of occult fecal blood loss belongs to the basic diagnostic procedures in gastroenterology. That examination is introductory method for screening, diagnosis and dispensarization of patients with colorectal cancer. Most frequently used tests in practice are biochemical and immunochemical tests. The aim of the study was to compare the results and clinical contribution of both kinds of tests. METHODS AND RESULTS: The results of immunochemical test Immocare (Care Diagnostica) and biochemical test Haemoccult (Röhm Pharma) were compared in a group of 253 patients (131 women, 122 men, average age 52.6 yr, range 19-88 yr). In all patients total coloscopy was subsequently performed. Sensitivity of immunochemical test was clearly higher (61.2%) than of biochemical test (29.4%), specificity was slight lower (95%, resp. 98%). Accuracy of Immocare test was also higher (82% than 72% of Haemoccult). CONCLUSIONS: Our results confirm advantages and competency of Haemoccult test for screening and dispensary programmes. More expensive and more difficult Immocare test is suitable for examination of symptomatic or risk patients.

The serologic screening for celiac disease in the general population (blood donors) and in some high-risk groups of adults (patients with autoimmune diseases, osteoporosis and infertility) in the Czech republic.

The prevalence of celiac disease (CD) was determined in healthy blood donors and in high-risk groups of adults (a total of 1835 adults--randomly selected 1312 healthy blood donors, 102 patients with primary osteoporosis, 58 patients with autoimmune diseases and 365 infertile women). It was calculated on the basis of a two-step serologic screening method--in the first step IgA and IgG antigliadin antibodies (AGA) and IgA anti-gamma-glutamyltransferase ('transglutaminase') antibodies (ATG) were estimated, in the second step sera positive for IgA AGA and/or IgA ATG were examined for antiendomysial IgA (AEA) antibodies. Immunoenzymic assay (ELISA) was used for determining of AGA and ATG antibodies; immunofluorescence method, performed on human umbilical cord tissue, was used for assaying of AEA antibodies. Total serum IgA level in only IgG AGA positive subjects was measured by routine turbidimetric method. 0.45% of healthy blood donors, 0.98% of osteoporotic patients, 2.7% of patients suffering from autoimmune disease and 1.13% of women with infertility considered as immunologically mediated were found to be positive in both steps of serologic screening (AGA and/or ATG and antiendomysium positive). The presumed high prevalence of seropositivity for CD in apparently healthy Czech adult population was confirmed. In the high-risk groups, the prevalence of seropositivity for CD was approximately 2-4 times higher than in healthy blood donors. The real prevalence of CD in the tested groups, however, can be estimated after performing small intestinal biopsy in the seropositive patients.

[Digitalization, archival storage and use of image documentation in the GastroBase-II system]. / Digitalizace, archivace a vyuzití obrazové dokumentace v systému GastroBase-II.

"GastroBase-II" is a module of the clinical information system "KIS-ComSyD"; The main part is represented by structured data-text with an expert system including on-line image digitalization in gastroenterology (incl. endoscopic, X-ray and endosonography pictures). The hardware and software of the GastroBase are described as well as six-years experiences with application of digitalized image data. An integration of a picture into text, reports, slides for a lecture or an electronic atlas is documented with examples. Briefly are reported out experiences with graphic editors (PhotoStyler), text editor (WordPerfect) and slide preparation for lecturing with the presentation software PowerPoint. The multimedia applications on the CD-ROM illustrate a modern trend using digitalized image documentation for pregradual and postgradual education.

Arginase activity determination. A marker of large bowel mucosa proliferation.

Arginase activity of the intestinal mucosa was tested as a proliferative marker in the adenoma-carcinoma sequence. The enzyme activity was determined by an end-point colorimetric method with L-arginine as substrate. Arginase activity was evaluated in 430 biopsy samples of large bowel mucosa, polyps and cancer tissue. The activities (U/g protein, mean +/- SE; n) were: normal mucosa 83.2 +/- 7.3; 25, adenomas 199.4 +/- 19.1; 40, carcinomas 1269.7 +/- 174.9; 40, inflammatory bowel disease 1210.7 +/- 247.1; 34. The arginase activity differs significantly in the adenoma-carcinoma sequence according to the Duncan's test (p < 0.05).

Molecular mimicry as a possible cause of autoimmune reactions in celiac disease? Antibodies to gliadin cross-react with epitopes on enterocytes.

Structural similarities between external antigen and self components are believed to be one of the possible causes of autoimmunity. This study describes the presence of similar structures shared by gliadin and enterocyte surface molecules recognized by antigliadin mAbs. The reactivity of mAbs to gliadin was followed by ELISA using fixed enterocytes, their brush-border membranes, or purified enterocyte antigen. The specificity of reaction was confirmed by ELISA inhibition studies and by immunohistochemical staining of rat tissue sections using biotin-avidin-peroxidase technique. Immunoprecipitation analysis of 125I-labeled intestinal epithelial cells using antigliadin mAb revealed the presence of two main cross-reactive molecules of 28 and 62 kDa. The 62-kDa and an associated 66-kDa protein were isolated by affinity chromatography. Immunoblotting analysis showed that a 28-kDa protein detected by immunoprecipitation also reacted with IgA of celiac disease patient sera.

The clinical information system GastroBase: integration of image processing and laboratory communication.

GastroBase, a clinical information system, incorporates patient identification, medical records, images, laboratory data, patient history, physical examination, and other patient-related information. Program modules are written in C; all data is processed using Novell-Btrieve data manager. Patient identification database represents the main core of this information systems. A graphic library developed in the past year and graphic modules with a special video-card enables the storing, archiving, and linking of different images to the electronic patient-medical-record. GastroBase has been running for more than four years in daily routine and the database contains more than 25,000 medical records and 1,500 images. This new version of GastroBase is now incorporated into the clinical information system of University Clinic in Prague.

Binding of gliadin to lymphoblastoid, myeloid and epithelial cell lines.

The aim of our work was to investigate the in vitro reactivity of gliadin peptides of natural and synthetic origin with various cell lines. We have found that all tested cell lines of human, mouse and rat origin were agglutinated by enzymically digested gliadin (peptic-tryptic- and peptic-tryptic pancreatic digest of alpha-gliadin) in a concentration dependent manner. In order to test the specificity of binding, inhibition studies were performed using a panel of sugars as well as natural and synthetic peptides derived from gliadin. We have found that among twelve tested sugars only fetuin and phosphomannan were able to inhibit the agglutination of K562 cells with peptic-tryptic- but not with peptic-tryptic pancreatic digest of alpha-gliadin. The lack of inhibition by gliadin peptides and most of the saccharides suggests that agglutinating activity of gliadin is the result of a nonspecific binding of gliadin to the cell membrane.

Characterization of human, mouse and rabbit anti-gliadin antibodies by ELISA and western blotting.

Monoclonal, hyperimmune rabbit and human serum anti-gliadin antibodies were analyzed by ELISA and immunoblotting techniques. In Western blotting the difference in reactivity between monoclonal and human antibodies was quantitative rather than qualitative. Rabbit antisera differed in reactivity according to the protein used for immunization. The rabbits immunized by the peptic-tryptic pancreatic digest of gliadin reacted similarly to the patients. In ELISA, significantly higher reactivity with crude, A-, glyc-gli, alpha-, beta- and omega-gliadins was found in the patients' sera than in controls.

[Comparison of immunochemical and biochemical tests for occult hemorrhage in feces]. / Srovnání imunochemického a biochemického testu okultního krvácení ve stolici.

The authors compared in a group of 104 patients assessment of occult haemorrhage in faeces made by the immunochemical test HemeSelect (HS-SmithKline Diagnostics) and the biochemical Haemoccult test (HT-Röhm Pharma). In all patients subsequently total coloscopy was performed. In the whole group the sensitivity of HS was 49.3% and of HT 16.0% (p << 0.001) and the specificity 72.4% and 100% (p << 0.01). The predictive value in polyps, 10 mm in size or larger, was 65.2% (positive) and 60.0% (negative). The assessed sensitivity and predictive values of HS do not permit to recommend immunochemical tests of this type as an alternative procedure to repeated colonoscopic checks in the dispensarization of high risk groups of colorectal cancer.

Effective peritoneal therapy of acute pancreatitis in the rat with glutaryl-trialanin-ethylamide: a novel inhibitor of pancreatic elastase.

The six hour peritoneal lavage with glutaryl-trialanin-ethylamide, a low molecular competitive inhibitor of pancreatic elastase (IC50-8 mumol/l), effectively suppresses the evolution of taurocholate induced acute pancreatitis in the rat. The lavage alone is followed by a marked decrease of fat necrosis and amylase and lipase activity in serum. The area of pancreatic haemorrhage was significantly reduced only after the lavage solution was supplemented with Glt-Ala3-NHEt. The effect was not enhanced by a bolus injection of the inhibitor before starting the lavage. The combination of Glt-Ala3-NHEt with aprotinin or nafamstate mesilate produced only marginal greater benefit. The effect of Glt-Ala3-NHEt on pancreatic haemorrhage is time and dose related even with delayed onset of the lavage. Animals treated with peritoneal lavage without Get-Ala3-NHEt lived longer than controls (p less than 0.05), but by 60 hours the survival rate of both groups was almost the same (76 v 74%). All animals lavaged with Glt-Ala3-NHEt survived 120 hours and the difference in the survival rate between this and both remaining groups was significant (100% v 76% v 74% - p less than 0.05). The results were considered favourable and preliminary clinical trials of Glt-Ala3-NHEt in subjects with acute pancreatitis justified.

[Comparison of immunochemical and biochemical methods for determination of occult fecal blood]. / Srovnání stanovení okultního krvácení ve stolici imunochemickou a biochemickou metodou.

The authors compared two tests of occult Fecal Blood Loss--the immunochemical Hemolex test based on agglutination of latex particles lined with antibodies against human haemoglobin and the biochemical Haemoccult test. Both tests were used to examine 55 patients invited to the department for endoscopic polypectomy or coloscopy as part of dispensarization after resection of colorectal carcinoma. The sensitivity of the Hemolex test (48.6%) is statistically significantly higher, as compared with the Haemoccult test (17.1%), the specificity is insignificantly lower in the Hemolex test (90%), as compared with the Haemoccult test (100%). The results indicate some advantages of the immunochemical examination of occult Fecal Blood Loss and the assumed area of its application.