X-ray diffraction studies of pancreatic calculi associated with nutritional pancreatitis.

The composition of pancreatic calculi in patients with tropical pancreatitis is unknown. At present, except for malnutrition, there are no known etiologic factors for chronic calcific pancreatitis in the tropics. We report the results of an x-ray diffraction study of 41 stones from 26 patients obtained at autopsy in the Kerala state in India. Calcite was present in all stones, vaterite in 12%, and a central amorphous material in 30%. The latter may be analogous to the protein plugs as nuclei for stones described by Sarles et al in patients with alcoholic pancreatitis.

Comparison of bentiromide test and rice flour breath hydrogen test in the detection of exocrine pancreatic insufficiency.

Bentiromide test (BT) has been recently approved in the United States for screening patients with chronic pancreatitis for exocrine insufficiency. A few reports have suggested that the rice flour breath hydrogen test (RFBHT)--i.e., breath hydrogen analysis after rice flour ingestion--may also be useful in diagnosing exocrine pancreatic insufficiency. We conducted this study to compare the diagnostic value of these two tests in chronic alcoholic (n = 14) and nutritional or tropical (n = 6) pancreatitis. False-positive results were not noted with either of these two tests in 12 healthy volunteers. BT was positive in 28.6% of patients with chronic alcoholic pancreatitis and in 16.7% of patients with tropical pancreatitis. In comparison, RFBHT was almost twice as sensitive as BT in detecting insufficiency in patients with alcoholic pancreatitis (50 vs. 28.6%) and four times as sensitive in patients with tropical pancreatitis (66.7 vs. 16.7%). Only one patient in our study had a positive BT but a negative RFBHT. We recommend RFBHT as a simple, safe, and inexpensive test in screening patients for exocrine pancreatic insufficiency.

Autoimmunity in type I (insulin-dependent) diabetes mellitus in North India.

Pancreatic islet cell, thyroid, gastric parietal cell, and adrenal autoantibodies were studied in 110 young insulin-dependent diabetics (type I; IDDM), 12 non-insulin-dependent diabetics (NIDDM), 26 patients with pancreatic diabetes, and 123 age- and sex-matched healthy controls. All the patients were aged 30 years or under at the onset of diabetes. Islet cell antibody was found in 31% of the patients with IDDM, but in only one patient with NIDDM, one patient with pancreatic diabetes, and one healthy control subject. Thyroid, parietal cell, and/or adrenal antibodies were present in 26% of the IDDM patients, 17% of the NIDDM patients, 12% of the patients with pancreatic diabetes, and 19% of the control subjects. There was no association between the presence of islet cell antibody and other organ-specific autoantibodies and any particular HLA phenotype. Data from the North Indian study have been compared with those from other populations of the world, similarities and differences have been brought out, and their significance has been discussed. The relative contribution of the autoimmune component in the etiopathogenesis of different forms of diabetes mellitus varies among the different populations of the world, accounting to some extent for the observed differences in incidence and clinical profiles.

Dietary cyanide and tropical malnutrition diabetes.

Two categories of diabetes are recognized in the temperate zone--ketosis-prone diabetes requiring insulin and diabetes not requiring insulin. Another unique type of diabetes occurs in the tropics. It has two forms, both different from either form of temperate zone diabetes. Type J and pancreatic diabetes are both characterized by youth onset, antecedent malnutrition, substantial insulin requirement, and resistance to ketosis. In the tropical countries where they are found, both forms are associated with specific dietary practices, including a nutritionally marginal protein intake. The close association with low protein intake distinguishes this form of diabetes from that occurring in North America, Europe, and Oceania. The geographic distribution of malnutrition diabetes, in addition to being limited to the tropics, coincides regularly with the consumption of tapioca (cassava) or other foods that contain cyanide-yielding substances. Ingested cyanide is normally detoxified, principally, by conversion to thiocyanate. This detoxification requires sulfur, derived principally from amino acid sources. Studies in the rat indicate a remarkable ability to detoxify ingested cyanide, a reduction in urinary thiocyanate excretion when protein intake is lowered (especially during growth), production of marked hyperglycemia by either oral or parenteral cyanide, and the development of cyanosis and epidermal changes when there is prolonged exposure to cyanide. Both the association of malnutrition diabetes with food cyanogens and our laboratory observations support a role for cyanide in its pathogenesis.