Origin and development of exocrine pancreatic insufficiency in experimental renal failure.

Chronic renal failure affects the physiological function of many organ systems. One of them is the exocrine pancreas. Although varying degrees of pancreatic insufficiency are the dominating clinical characteristic of uraemic pancreatic disease, it remains unclear whether this disease should be regarded as a manifestation of chronic pancreatitis, arising from recurring attacks of acute pancreatitis, or represents a distinct entity. The exocrine pancreas was studied in a model of experimental renal failure. The pancreas was removed from each rat at selected time points over eight weeks after subtotal nephrectomy and from a standard rat model of pancreatitis for comparison. The data show that the in vitro secretory response is considerably changed in renal failure (increased during early acute and decreased during chronic renal failure). While the pancreatic content of digestive enzymes progressively declines, DNA and protein synthesis increase over time. Acinar cell deletion is increased and accompanied by an increased rate of mitosis. This increased cellular turnover is not associated with tissue oedema, pancreatic fibrosis, inflammatory changes, autophagocytosis or subcellular redistribution of lysosomal hydrolases, all of which are characteristic for pancreatitis. The ultrastructural changes of uraemic pancreatic disease bear no resemblance to the changes seen in pancreatitis. It is concluded that the morphological and biochemical changes in early uraemic pancreatic disease are quite distinct, correspond with toxic damage of the pancreas, and are dominated by functional impairment and an increased cellular turnover.

In vitro perfusion and incubation of rat pancreatic lobules in a kinetic system.

The use of pancreatic lobule preparations is one of the well-established approaches to study stimulus-secretion coupling in the exocrine pancreas in vitro. We have developed a kinetic system for the perfusion and intermittent incubation of rat pancreatic lobules. This model allows repeated hormone stimulation for up to 3 h while permitting rapid changes of the cellular environment with no accumulation of secretory or metabolic products. Tissue viability could be demonstrated over 6 h by in vivo toluidine blue exclusion, histology and electron microscopy. Lactate dehydrogenase leakage from cells over 6 h was only 2.4% of total content. No activated trypsin was detected in the perfusion medium. A biphasic dose response was established for cholecystokinin stimulation with a maximal response at 10(-8) M. We conclude that kinetic perfusion and incubation are technically feasible with rat pancreatic lobules. This in vitro model appears particularly suited for the investigation of pharmacologic and metabolic effects on the pancreatic acinar cell when rapid changes of the cellular environment are required and when the accumulation of secretory and metabolic products must be avoided. The technique described requires neither protease inhibition in the medium nor collagenase treatment of the cells.

The information needs and fears of patients with inflammatory bowel disease.

A questionnaire containing a list of 36 questions and nine "fear factors" was sent to 139 patients with inflammatory bowel disease. Patients were asked to select the most and the least important questions and fear factors. Furthermore, the level of information and the source of information were recorded. 58% of the patients responded. The most important questions selected were possibilities of remission of the disease, and of developing cancer (47% and 43% of all answers respectively). Women judged questions regarding cancer, sex life, side effects of diagnostic techniques or drugs to be important more often than men, who were more interested in the cause, symptoms and natural history of the disease. Cancer was the fear factor selected most often (52%), being more important to patients with ulcerative colitis than to those with Crohn's disease, who in turn were more afraid of surgery than those with ulcerative colitis. 77% of the patients felt they had little or too little information. 87% received information from their physicians, 75% wanted to continue doing so. 62% wanted additional information from booklets, 18% from self-help groups. Thus, much information is lacking and many unjustified fears exist in patients with inflammatory bowel disease. This could probably be improved by providing more and better information by improved personal communication, and additionally from booklets or self-help groups.

[Pancreas divisum as a possible cause of misinterpretation in ERCP, computed tomography, sonography and MDP]. / Das Pancreas divisum als mögliche Ursache von Fehlinterpretationen bei ERCP, Computertomographie, Sonographie und MDP.

In 488 patients endoscopic retrograde pancreatography (ERP) revealed a pancreas divisum in 21 (4.3%): in 17/21 patients we found a complete, in 4/21 an incomplete separation of the pancreatic ducts. The pancreas divisum is caused by a malfusion of the ductal system. On examination by ultrasound, computed tomography or hypotonic duodenography this variant can suggest an inflammation or tumour of the head of the pancreas. A definite diagnosis is possible by ERP only. Since the small ventral duct can be confused with an alteration caused by inflammation or by a tumour, to much of contrast medium can be injected. Pancreas divisum is often associated with a chronic pancreatitis which can be demonstrated via ERP of the dorsal duct through the accessory papilla.

[Peritoneovenous shunt in ascites therapy. Complications and their treatment]. / Peritoneo-venöser Shunt in der Aszitestherapie. Komplikationen und deren Behandlung.

Complications occurred in 29 of 37 patients after ascites retransfusion (n = 16) or introduction of a peritoneovenous shunt (n = 21). Blood clotting disturbances, that could either be successfully treated with drugs or which led to interruption of the reinfusion, appeared in 38%. Estimation of plasminogen proved to be of reliable prognostic value thus enabling prophylactic measures to be taken. Post-operatively 14 patients had transient fever not requiring specific treatment. Local fibrinolysis or shunt revision was successful in three patients with shunt thromboses. According to our experience most complications can be avoided by prophylactic and therapeutic measures.

[Changes in the esophageal wall following sclerotherapy of varices--roentgen morphology and therapy]. / Veränderungen der Osophaguswand nach Varizensklerosierung--Röntgenmorphologie und Therapie.

Endoscopic sclerotherapy of esophageal varices is a widely used procedure. It reduces the frequency of rebleeding and improves the survival of cirrhotics with portal hypertension. The intravariceal or paravariceal injection of sclerosing agents causes structural changes of the esophageal wall recognisable radiologically. Stricture is a late complication which occurs in about 10 percent. In residual dysphagia balloon dilatation is recommended.

[Hemorrhage into a liver adenoma associated with long-term use of oral contraceptives]. / Spontane Blutung in ein Leberadenom nach mehrjahriger Einnahme von Antikonzeptiva.

A 39-year-old woman was evaluated for acute midepigastric pain. The patient was never severely ill; her only medication was an oral contraceptive (OC) which she took regularly over the last 12 years. Abdominal ultrasonography and computed tomography revealed bleeding into a liver tumor. At laparoscopy, 3 adenomas of the liver were detected. Bleeding was restricted to 1 tumor and did not require surgical intervention. OC medication was discontinued, and the patient was followed over more than 3 years. The patient was doing very well; ultrasonographically, the liver tumors became gradually smaller.

[Bile duct endoprostheses. Insertion using a combined endoscopic-radiologic technic]. / Gallengangsendoprothesen. Installation in kombinierter endoskopisch-radiologischer Technik.

Percutaneous transhepatic biliary drainage is a proven method for treating obstructive jaundice due to malignancy. However, the rate of complications for primary internal drainage is relatively high. Consequently, various types of biliary endoprostheses which can be introduced transhepatically or endoscopically have been developed. These prostheses also have serious disadvantages: there is a high risk of dislocation or obstruction. The present paper describes the technique of combined endoscopic-radiological introduction of large biliary prostheses and discusses the advantages of this method.

[Endoscopic and biopsy findings in the esophageal, gastric and duodenal mucosa before and after radiotherapy for Hodgkin's disease]. / Endoskopisch-bioptische Befunde der Osophagus-, Magen- und Duodenalschleimhaut vor und nach Strahlentherapie bei Morbus Hodgkin.

Esophago-gastro-duodenoscopies with multiple mucosa biopsies were performed before and after irradiation of the mantle field or the spleen pedicle in 13 patients with Hodgkin's disease in stage I and II. For the irradiation the photons of a 4 MeV linear accelerator were applied with focal doses of 40 to 44 Gy. Contrast simulator radiographs were made in order to verify the position within the irradiation field of the organs from which biopsies were taken. In 0/10 patients examined before the irradiation, 0/5 patients examined less than 15 weeks after the irradiation, and 0/12 patients examined 15 weeks or later after the irradiation, histomorphologic investigation of the mucosa of the esophagus showed no pathologic findings. With the same intervals of examination related to irradiation, the gastric mucosa showed a pathologic histomorphology in 1/13, 7/9, and 5/9 patients, respectively, and the duodenal mucosa in 0/13, 5/9, and 2/9 patients, respectively. With the exception of one ulcer in the duodenal bulb the histopathologic findings as well as the macroscopic findings were neither significant nor characteristic, i.e. not radiospecific. Most of these findings were inflammatory alterations of the mucosa, erosions, and capillarectasies.

Zinc and vitamin A deficiency in patients with Crohn's disease is correlated with activity but not with localization or extent of the disease.

A study of serum zinc and plasma vitamin A concentrations in 54 patients with Crohn's disease was performed. Compared with controls the patients had significantly lowered zinc and vitamin A concentrations. There was a marked correlation between zinc and vitamin A and the activity of the disease, as measured by the Crohn's disease activity index, and a weaker correlation with serum proteins considered to be indicators of disease activity. No correlation was found to vitamin B12 absorption, to the localization of the disease, or to previous ileal resection. The results suggest that zinc and vitamin A deficiency occurs in patients with active Crohn's disease and is not primarily caused by absorption abnormalities. Substitution might be helpful or even necessary in patients with highly active disease.

[Immunogenetic findings in Crohn disease, ulcerative colitis and gluten sensitive enteropathy]. / Immungenetische Befunde bei Morbus Crohn, Colitis ulcerosa und glutensensitiver Enteropathie.

Immunogenetics explain the influence of genetic dispositions and regulation mechanisms on the defence mechanisms of organisms. In this paper the interrelationship between immunogenetic findings and Crohn's disease, ulcerative colitis and glutensensitive enteropathy are presented. The association with HLA-antigens and the complement factors Bf and C 4 are described. An increased association of HLA-antigens with Crohn's disease and ulcerative colitis have not been observed, with one exception, the association between HLA-Bw 35 (53%) and ulcerative colitis in a particular ethnic group in Israel. In contrast, there is a distinct association between the complement allotype Bf-F and Crohn's disease (68%) and ulcerative colitis (50%), compared with controls (29%). Glutensensitive enteropathy shows no increased occurrence of complement factors however there is an association with HLA-B8 (83%) DR 3 (94%) and DR 7 (61%). The phenotype description of the genes of the main histocompatibility complexes allows, amongst others, a conclusion concerning the pathogenesis and diagnosis of certain diseases. A new approach to these diseases has been introduced.

[Significance of sonographic course controls in acute pancreatitis]. / Die Bedeutung sonographischer Verlaufskontrollen bei der akuten Pankreatitis.

Two patients with complicated acute pancreatitis are demonstrated. Sonographic factors are compared to laboratory and clinical findings. Ultrasound can add relevant information for classification and thereby supply an indication for surgery in patients with acute pancreatitis. This is especially true since laboratory classification of the grade of the disease is as yet not generally accepted.

[Extraintestinal complications of Crohn disease, demonstrated in a patient]. / Extraintestinale Komplikationen des Morbus Crohn, dargestellt an einem Patienten.

A patient with different extraintestinal complications of Crohn's disease is demonstrated. The case allows a discussion of frequency and importance of such complications in Crohn's disease. Vitamin-und trace element deficiency, protein loss and renal complications are the main complications. Determination of vitamin and trace elements may early detect beginning extraintestinal complications and may induce a corresponding therapy.

[Oral contraceptives and benign tumorous conditions of the liver (author's transl)]. / Orale Kontrazeptiva und gutartige tumoröse Veränderungen der Leber.

Tumorous lesions of the liver were diagnosed by means of angiography, sonography and laparoscopy in six patients on oral contraceptives for a long time. These lesions were identified as liver cell adenoma (1), focal nodular hyperplasia (4) and cavernous hemangioma (1). The relationship between oral contraceptives and liver disorders is well-known. All cases of focal nodular hyperplasia show vascular alterations which may be important in the discussion of oral contraceptives being responsible. In contrast to liver cell adenoma and hemangioma, focal nodular hyperplasia may be considered as a nodular reparative regeneration of the parenchyma following focal parenchymal necrosis due to segmental vascular occlusion (i. e. thrombosis or fibrotic intimal obliteration). This lesions can therefore not be defined as a true neoplasm. The clinical findings are uncharacteristic, whereas selective hepatic artery angiography, shows typical features that distinguish liver cell adenoma from focal nodular hyperplasia. Regular medical examinations are recommended for women on continuous oral contraceptives for more than five years, because this group of patients is threatened by serious sequelae including intrahepatic and abdominal hemorrhage.

PIP: Tumorous lesions of the liver were diagnosed by means of angiography, sonography, and laparoscopy in 6 patients on (OCs) oral contraceptives for a long time. These lesions were identivied as liver cell adenoma, focal nodular hyperplasia, and cavernous hemangioma. The relationship between OCs and liver disorders is well-known. All cases of focal nodular hyperplasia show vascular alterations which may be important in the discussion of OC responsibility. In contrast to liver cell adenoma and hemangioma, focal nodular hyperplasia may be considered as a nodular reparative regeneration of the parenchyma following focal parenchymal necrosis due to segmental vascular occlusion (i.e., thrombosis or fibrotic intimal obliteration). This lesion can therefore not be defined as a true neoplasm. The clinical findings are uncharacteristic, whereas selective hepatic artery angiography shows typical features that distinguish liver cell adenoma from focal nodular hyperplasia. Regular medical examinations are recommended for women on continuous OCs for more than 5 years, because this group of patients is threatened by serious sequelae including intrahepatic and abdominal hemorrhage. (Author's modified)

[Severe and prognostically unfavourable forms of tick-borne encephalitis (early-summer meningo-encephalitis) in Freiburg (author's transl)]. / Schwere und ungünstige Verlaufsformen der Zeckenenzephalitis (FSME) 1979 in Freiburg.

Eight patients with proven tick-borne encephalitis (early-summer meningo-encephalitis; central European encephalitis) were treated in 1979. The disease ran a severe course in four: one died after six weeks of coma and pneumonia with right-heart failure. Another patient is in coma for more than 40 weeks. A third patient had severe flaccid tetraplegia more than 10 weeks after initial coma. The fourth patient still had leg paresis after nine weeks, her left arm also being largely paralysed. This high incidence of severe forms of the disease differs from other published reports.