Does acute ingestion of large amounts of alcohol cause pancreatic injury? A prospective study.

The contribution of ethanol to the pathogenesis of acute pancreatitis has been questioned for a long time. The authors asked whether acute ingestion of large amounts of alcohol may lead to pancreatic injury, as assessed by serum amylase levels, clinical picture, and abdominal ultrasound. Therefore, all patients (N = 122) admitted to our medical emergency ward with the diagnosis of alcohol intoxication were evaluated prospectively during a 12-mo period. Of these, 78 (56 M, 22 F; mean age 36 +/- 15) could be evaluated. The other 44 were excluded because of incomplete data (n = 18), mixed intoxications (n = 8), repeated admission (n = 9), incorrect diagnosis on admission (n = 7), and chronic pancreatitis (n = 2). Serum ethanol, amylase, and GOT were measured. Serum ethanol was 246 +/- 122 mg/dL (3-500 mg/dL), amylase 83 +/- 44 U/L (27-361 U/L), and GOT 25 +/- 37 U/L (5-271 U/L) without significant differences among the genders. No correlation between serum ethanol and serum amylase levels could be detected.

[Diagnosis of phlebothrombosis using color-coded duplex sonography. A prospective comparison with phlebography]. / Diagnostik der Phlebothrombose durch farbkodierte Duplexsonographie. Ein prospektiver Vergleich mit der Phlebographie.

In a prospective study the reliability of colour-coded duplex-sonography (CCDS) and phlebography in the diagnosis of deep leg and pelvic vein thrombosis was compared. In 82 consecutive in- or out-patients (42 men, 40 women; mean age 53 [19-86] years) with clinically suspected leg or pelvic vein thrombosis the results of 275 phlebographies (reference method) and 275 CCDS were compared on admission and during follow-up. The two methods were performed less than 6 hours apart. In the diagnosis of thrombosis the sensitivity of CCDS was 99%, specificity 80%. In 88% of all tests, the different thrombosis levels, as diagnosed by phlebography, were also demonstrated by CCDS. These data indicate that, if the clinical picture of suspected deep leg or pelvic vein thrombosis is unclear, CCDS should be done first. Phlebography should be performed only if the results of the former are inconclusive.

Use of immunoscintigraphy in the diagnosis of fever of unknown origin.

Fever of unknown origin (FUO) has been defined as an elevation in temperature (38 degrees C) for at least 2-3 weeks despite intensive investigation. The value of immunoscintigraphy with the technetium-99m-labelled anti-granulocyte antibody anti-NCA-95 (BW 250/183, IgG1) was studied retrospectively in 34 consecutive patients with FUO. Every effort was made to confirm a diagnosis, including methods such as ultrasonography, computed tomography, magnetic resonance imaging, bacteriological tests, surgical intervention and clinical follow-up. In 58.8% of the patients, an infectious cause for the fever was found, in 30.2% of the patients, a benign or malignant haematological disease, pancreatitis or thyrotoxicosis was found. No cause for fever could be found in 11%. The overall diagnostic sensitivity and specificity of immunoscintigraphy for infection were 40% and 92% respectively. The positive predictive value was calculated to be 88% and the negative predictive value was calculated to be 52%. False-negative scans were especially noted in patients with endocarditis, pneumonia and small brain abscesses, where the lesions did not exceed a diameter of 0.5 cm. If patients with endocarditis were excluded, the imaging sensitivity and specificity were increased to 57% and 95%. This study demonstrates that 99mTc-anti-NCA-95 scanning is able to localize infectious causes of FUO, other than endocarditis.

[Encephalitis in Legionella bozemanii pneumonia]. / Enzephalitis bei Legionella-Bozemanii-Pneumonie.

A 44-year-old man, a known alcoholic and heavy smoker, was hospitalized with high fever and respiratory failure which a few hours later required intubation and artificial ventilation, although the chest x-ray had been unremarkable. Later serial chest x-ray films showed intrapulmonary infiltrations, while Legionella Bozemanii was demonstrated by direct immunofluorescence. Cranial computed tomography was unremarkable, despite the onset of tetraparesis and a severe midbrain syndrome. Cerebrospinal fluid contained merely mild lymphocytic pleocytosis. However, magnetic resonance imaging revealed symmetrical demyelinization foci in the brainstem as a sign of encephalitis. The neurological deficits regressed almost completely after several weeks of antibiotic treatment and rehabilitation measures over several months.

Duodenal pancreatectomy with occlusion of the pancreatic duct.

In 1978 partial duodenopancreatectomy with Ethibloc duct occlusion of the pancreatic remnant was introduced for use in patients with severe chronic cephalic pancreatitis. Our intention was to remove the largely destroyed part of the gland, and to induce controlled glandular atrophy in the residual portion in order to prevent further recurrence of pancreatitis. Since then this surgical procedure has been performed in 328 patients. The perioperative mortality was 1.2%, the complication rate requiring relaparotomy 7.1%. So far pancreatitis has recurred in only 2.2% of cases, due, we believe, to incomplete ductal block. Some 53% of the patients remained free of pain and symptoms, while 35% have occasional minor complaints. In a prospective follow-up study of 23 patients, Ethibloc duct occlusion was shown to be highly effective in inducing controlled atrophy of the gland and thereby terminating the inflammatory process. Endocrine function was preserved at the post-resectional level.

Transpapillary miniscopy and mini-biopsy of the pancreatic duct.

This paper reports on the new combined examination of peroral transpapillary fine-caliber endoscopy (miniscope 0.5 mm in diameter) with mini-biopsy of the pancreatic duct in 10 patients and 19 surgical pancreas resection preparations. With this technique, endoscopic-retrograde inspection of the whole length of the pancreatic duct is possible without the need for papillotomy. In the case of pancreatic duct changes due to carcinoma of the pancreas, and chronic pancreatitis, the ductal lesions can be inspected. Furthermore, with the aid of a new mini-biopsy forceps (1.5 mm in diameter), material for histological evaluation can be much more efficiently obtained than was normally possible with conventional biopsy forceps (2.2 mm). This new endoscopic-bioptic technique promises to improve the diagnostic reliability in pancreatic duct lesions requiring clarification.

Transpapillary cholecystoscopy.

This report describes the inspection of the inside surface of the gallbladder and the cystic duct by a newly available catheter and endoscopic system, with the aid of retrograde endoscopy. Using our newly developed endoscopic retrograde catheter system, we were able to cannulate the gallbladder in nearly 80% of all cases. No papillotomy is needed. Owing to its high degree of flexibility and relative robustness, coupled with brilliant optical quality, the new 0.5 mm miniscope permits careful and virtually complete inspection of even such small structures as the tortuous cystic duct.

Severe chronic cephalic pancreatitis: use of partial duodenopancreatectomy with occlusion of the pancreatic duct in 289 patients.

Partial duodenopancreatectomy and occlusion of the remaining ductal system by Ethibloc to induce rapid exocrine atrophy for treatment of severe chronic cephalic pancreatitis was introduced in our department in January of 1978. Since then, this surgical procedure has been performed in a total of 289 patients. Postoperative morbidity was 12.2%, 5 pancreatic and 3 biliary fistulas occurred. Postoperative mortality was 1% and relapses of pancreatitis occurred in only 2.2% due to incomplete filling of ducts with Ethibloc. A total of 88.2% of patients became pain-free and symptomless, 10.8% voiced minor complaints, and 85.9% gained an averaged of 7.8 kg weight postoperatively. We conclude that Ethibloc occlusion is highly effective in inducing complete exocrine atrophy, thus abolishing the inflammatory process and preventing relapses of chronic pancreatitis and preserving the endocrine function from further impairment. This was demonstrated by biochemical assays during a 36-month follow-up in a prospective study in 23 of 289 patients. Our results compare favorably with and are superior to results from any other operative procedure for chronic cephalic pancreatitis. We consider partial duodenopancreatectomy combined with Ethibloc occlusion of the pancreatic duct the procedure of choice in the surgical treatment of severe chronic cephalic pancreatitis.

Miniscopes in gastroenterological endoscopy--inspection of the gallbladder and the biliary and pancreatic duct systems in autopsy specimens.

This report describes a newly available endoscopic system, the purpose of which is to inspect the common bile duct, gallbladder, cystic duct and the pancreatic duct with the aid of retrograde endoscopy. A miniscope examination of the gallbladder was carried out in eight out of ten autopsy specimens, and the entire pancreatic duct was inspected in nine out of ten specimens after successful transpapillary catheterisation. The procedure described in this paper opens up a new diagnostic and therapeutic approach to the gallbladder, biliary tree and the pancreatic duct.

Mechanical lithotripsy of bile duct stones in 209 patients--effect of technical advances.

Between 1982 and 1987, mechanical lithotripsy of common bile duct (CBD) stones was performed in 209 patients (mean age +/- SD: 72 +/- 10 years), using self-constructed lithotripters and baskets with breaking strengths of approximately 50 and 100 kg between 1982 and 1986, and stronger and bigger baskets with breaking strengths of approximately 125 kg since 1987. Patients with single (49.3%) and multiple stones (50.7%) were distributed about equally. Stone size ranged between 4 and 80 mm (mean longitudinal diameter 18 +/- 9 mm, mean transversal diameter 13 +/- 3 mm), with a majority of the patients (61.2%) having stones of between 10 and 19 mm, and about one-third (32.1%) of the patients with stones greater than or equal to 20 (20-80) mm. The overall success rate of mechanical lithotripsy in all 209 patients treated between 1982 and 1987 was 87.6% including 79.1% for CBD stones greater than or equal to 20 mm and 67.6% for stones greater than or equal to 25 mm. The introduction of baskets with breaking strengths of approximately 125 kg in 1987 considerably increased the success rate of mechanical lithotripsy, especially for "large and giant" CBD stones, to 92.3% (greater than or equal to 20 mm) and 85.7% (greater than or equal to 25 mm), respectively.

[Amino acid level in plasma--expressed as alpha-amino-nitrogen--reaction to stimulation of the exocrine pancreas: approaches to a new pancreatic function test]. / Aminosäurespiegel im Plasma--dargestellt als alpha-Amino-Stickstoff--reagieren auf Stimulation des exokrinen Pankreas: Ansätze für einen Pankreasfunktionstest.

We determined by the ninhydrin method the plasma amino acid (AA) levels prior to, during and following, a 1-hour i.v. infusion of 1 U/kg body weight each of secretin and pancreozymin in patients with normal (n = 74) or reduced (n = 39) exocrine pancreatic function, as assessed by the duodenal aspiration test. The results of the two tests correlated significantly with each other (p less than 0.001). A maximum AA decrease of greater than or equal to 12% was observed in all patients with a normally functioning pancreas (specificity 100%), and of less than 12% in all patients with medium to high-grade impairment of pancreatic function (sensitivity 100%). Since, however, low-grade pancreas insufficiency (20-40% of the mean normal enzyme output) is recognized in fewer than one-half of the cases, the overall sensitivity of the AA-consumption test decreases to 69%. The results can, however, be improved by: 1) Calculating the mean percentage AA decrease with a limit value of 5% (sensitivity 90%); 2) determining individual AA with pancreas-specific absorption, such as serine (sensitivity 92%); 3) dropping the lower normal value of exocrine pancreatic function to 25% of the normal mean enzyme output (sensitivity 96%). Diseases that may be associated with the most common condition that causes pancreatic insufficiency--chronic pancreatitis--and which have an influence on AA metabolism, such as cirrhosis of the liver and diabetes mellitus, have no influence on the accuracy of the AA consumption test, which, considered overall, represents a competitive alternative to other tubeless tests of pancreatic function.

NMR spectrometry. A new method for total stool fat quantification in chronic pancreatitis.

In the present investigation, suitability of nuclear magnetic resonance (NMR) spectrometry for total stool fat quantification in patients with normal or impaired exocrine pancreatic function (chronic pancreatitis) has been analyzed in comparison with a conventional chloroform-methanol extraction technique. Basic temperature-dependence studies of NMR spectrometry (90 degrees/180 degrees radiofrequency pulse sequence) on 21 chloroform-methanol extracted pure total stool lipid standards (weight range: 0.05-1.6 g) revealed significantly (P less than 0.05) improving correlations between NMR signal amplitudes and corresponding weights at increasing temperatures (r = 0.952/40 degrees C, r = 0.965/60 degrees C, r = 0.988/80 degrees C), thus indicating 80 degrees C as optimal temperature for NMR spectrometric total stool fat quantification. In subsequent comparative measurements of lyophilized stool samples, NMR spectrometry (at 80 degrees C) and conventional chloroform-methanol extraction provided significantly (P less than 0.001) correlated results with respect to total fecal fat contents/day of quantitatively collected and homogenized stools in 93 patients with known exocrine pancreatic function (secretin-pancreozymin test), irrespective of whether correlations were determined for all 93 patients (r = 0.983) or separately for patients with normal (N = 45; r = 0.867), moderately reduced (N = 31; r = 0.946), or highly reduced (N = 17; r = 0.992) exocrine pancreatic function and correspondingly increased total fecal fat excretions.

Whipple's procedure plus intraoperative pancreatic duct occlusion for severe chronic pancreatitis: clinical, exocrine, and endocrine consequences during a 3-year follow-up.

The present investigation provides follow-up data (up to 36 months) of exocrine and endocrine pancreatic function, inflammatory activity, pain, and body weight in 23 chronic pancreatitis patients submitted to Whipple's procedure plus intraoperative Ethibloc occlusion of the remaining pancreatic duct system between January 1983 and February 1984. Clinically, Whipple's procedure plus intraoperative pancreatic duct occlusion resulted in almost complete and continuous cessation of pain as well as significant (p less than 0.05) increase in body weight. With regard to exocrine pancreatic function (Secretin-Pancreozymin test, plasma amino acid consumption test, Pankreolauryl test, fecal chymotrypsin determination), intraoperative pancreatic duct occlusion was shown to induce high-grade insufficiency and thus exocrine parenchymal atrophy in all patients. Simultaneously, the inflammatory process (represented by serum levels of trypsin, lipase, and pancreatic isoamylase) was terminated in all 23 patients. Endocrine pancreatic function, evaluated by serum levels of insulin and C-peptide measured under fasting conditions and subsequent maximal combined beta-cell stimulation as well as corresponding integrated hormone releases, was reduced by partial pancreas resection by about 50%, while there was no further impairment during the 36-month follow-up period in consequence of additional intraoperative pancreatic duct occlusion. Altogether, Whipple's procedure plus intraoperative Ethibloc occlusion of the residual pancreatic duct system seems suitable for termination of the inflammatory process and thus preservation of residual endocrine pancreatic function in chronic pancreatitis.

Decrease in plasma amino acid level after secretin and pancreozymin as an indicator of exocrine pancreatic function.

Total plasma amino acids were determined by the ninhydrin method in 37 controls and 30 patients with chronic pancreatitis and normal (n = 7) pancreatic enzyme output or mildly (n = 6), moderately (n = 8), and severely (n = 9) reduced pancreatic enzyme output. Intravenous injection of synthetic secretin did not change plasma amino acid levels. During a combined intravenous infusion of secretin (1 CU/kg X h) and pancreozymin (1 Ivy dog unit/kg X h), amino acid concentrations decreased maximally by 31% +/- 19% (mean +/- SD) in controls, but only by 6.3% +/- 4.7% in patients with exocrine pancreatic insufficiency (p less than 0.001 vs. controls). At a cutoff limit of less than or equal to 12% for the decrease in total amino acids, mild exocrine insufficiency (20%-40% of mean normal chymotrypsin output) was identified with a sensitivity of 67%, whereas moderately to severely impaired function was detected in every case (overall sensitivity 91%). Pancreatic function, as assessed by duodenal intubation and the tubeless amino acid test, was significantly correlated (e.g., rs = 0.73 for chymotrypsin output, p much less than 0.001). In 15 controls and 13 patients with mildly (n = 5) to severely impaired pancreatic function, individual amino acids were estimated. Plasma serine kinetics completely distinguished both groups. Kinetics of serine, valine, isoleucine, and histidine correlated even better with pancreatic function than those of total amino acids.

[Comparison of CA 50 and CA 19-9 tumor markers in benign and malignant diseases of the upper gastrointestinal tract]. / Vergleich der Tumormarker CA 50 und CA 19-9 bei benignen und malignen Erkrankungen des oberen Gastrointestinaltraktes.

Tumour-associated antigens CA 50 and CA 19-9 were determined in serum of 208 patients. Specificity of both neo-antigens as tumour markers was equally good, at 100% and 95%, in patients without malignancy or gastrointestinal disease, respectively, using an upper limit of normal of 17 U/ml for CA 50 and 37 U/ml for CA 19-9. Benign diseases of the upper gastrointestinal tract, such as pancreatitis, cholestasis or cirrhosis of the liver, reduce the specificity of CA 50 more than of CA 19-9. For example, specificity of CA 50 is only 33% for choledocholithiasis, but 74% with CA 19-9. The sensitivity of both closely related sialogangliosides in malignancies of the upper GI tract is similar, with the usual normal limits: in pancreas carcinoma 77% for CA 50, 81% for CA 19-9; in biliary tract carcinoma 80% for CA 50, 90% for CA 19-9; in gastric carcinoma 40% for CA 50, 50% for CA 19-9. But if one equalizes the upper limits of normal for both markers to a common 95% specificity, the tumour-indicating sensitivity of CA 19-9 clearly surpasses that of CA 50. Malignant tumours not recognized by increased levels of CA 19-9 also escape serological diagnosis with CA 50.

[Metronidazole in the treatment of Crohn disease. Results of a controlled randomized prospective study]. / Metronidazol in der Behandlung des Morbus Crohn. Ergebnisse einer kontrollierten randomisierten prospektiven Studie.

In a controlled, randomised prospective study on 52 patients with active ileocolitis Crohn (n = 44) or discharging fistulae (n = 18) metronidazole monotherapy was compared with a combination of cortisone and salazosulfapyridine, and of cortisone, salazosulfapyridine and metronidazole, respectively. Therapeutic efficacy was judged by various clinical, laboratory and haematological activity parameters, as well as by closure of discharging fistulae. Although analysis of variance showed no significant differences in the changes in individual activity parameters between the three groups, the combination of cortisone, salazosulfapyridine und metronidazole normalised the nine activity parameters more often than the other treatments. Metronidazole alone led to complete closure of discharging fistulae in 40% of cases and produced a clear reduction in fistula discharge in a further 20%. A more effective fistulae therapy could not be achieved even when combined with cortisone and salazosulfapyridine. In view of the dose-related serum concentrations of metronidazole and its minimal inhibitory concentration for anaerobic bacteria, the dose of metronidazole in ileocolitis Crohn should not be less than 400 mg/d. After evaluation of all findings, and taking into account the neurological side effects of long-term metronidazole therapy, the main indications for metronidazole in ileocolitis are failure of cortisone and salazosulfapyridine as well as discharging fistulae.

NMR spectrometric stool fat analysis--a new technique for quantifying steatorrhea and establishing the indication for enzyme replacement in chronic pancreatitis.

In 93 patients with known exocrine pancreatic function (secretin-pancreozymin test), NMR spectrometry and chloroform-methanol extraction of quantitatively collected, homogenized and lyophilized stools provided significantly correlated results with respect to stool fat concentration (r = 0.872) and total stool fat excretion/day (r = 0.983). In 83% of 24 patients with total stool fat excretion/day of more than 15 g (chloroform-methanol extraction), the indication for enzyme replacement was also established by stool fat concentrations of more than 35% determined by NMR spectrometry, irrespective of whether stool fat was measured in total stools or in 3 consecutive unhomogenized samples. In the remaining (17%) patients total stool fat excretion/day was only slightly elevated (16-21 g). Interestingly, in only 58% of patients actually needing enzyme replacement, did the secretin-pancreozymin test reveal a reduction of stimulated enzyme secretion to below 15% of the lower normal limit. The results indicate that NMR spectrometry of lyophilized samples of 3 consecutive unhomogenized stools is suitable for stool fat quantitation and for establishing the indication for enzyme replacement in chronic pancreatitis.