Showing papers on "Pancreatitis published in 1978"

Susceptibility of the pancreas to ischemic injury in shock.

Abstract: The pancreas, like the kidney, is highly vulnerable to ischemic necrosis. This form of pancreatic injury may express itself as prolonged hyperamylasemia with only minimal signs or symptoms of inflammation, or may produce severe pancreatitis followed by abscesses and death. Autopsy examination of patients dying after oligemic shock showed a 9% incidence of major pancreatic injury if there was not concomitant acute renal tubular necrosis (ATN), but a 50% incidence in those with ATN. Similarly, among patients dying after non-oligemic shock, 12% of those without ATN had major pancreatic injury but 35% with ATN also had pancreatic ischemic injury. Among 13 selected patients examined prospectively after being in shock, pancreatic injury was indicated by hyperamylasemia, hyperlipasemia, elevated amylase/creatinine clearance ratio, and elevated circulating isoamylases specifically of pancreatic origin. Four of the 13 had clinical manifestations of pancreatitis. Not only must shock be added to this list of causes of pancreatitis, but pancreatic ischemia due to hypoperfusion may also be the critical factor which causes the progression from edema to necrosis in other forms of pancreatitis, including those associated with alcohol and biliary disease.

Multicenter survey of the etiology of pancreatic diseases. Relationship between the relative risk of developing chronic pancreaitis and alcohol, protein and lipid consumption.

Abstract: The relationship between the average daily intake of alcohol and the risk of developing chronic pancreatitis was studied in two surveys, one in Marseille (France), the other in 9 centers, in Caucasian

The Role of Peritoneal Lavage in Severe Acute Pancreatitis

Abstract: Encouraged by reports of the therapeutic efficacy of peritoneal lavage in small series of five or six patients with acute pancreatitis, we have evaluated this treatment in 24 patients with "severe" pancreatitis. One hundred and three patients with "severe" pancreatitis (28% mortality) were separated from 347 with "mild" pancreatitis (0.9% mortality) by previously described early objective signs. Early treatment (Day 0-7) of "severe" pancreatitis included peritoneal lavage through catheters placed nonoperatively in 18 (Group A) and by catheters placed at laparotomy in six (Group C). Early treatment of nonlavaged patients with "severe" pancreatitis was by standard nonoperative measures in 61 (Group B) and included early operation in 18 (Group D). Lavage was continued for 48-96 hours, usually using 36-48 L/24 hours of balanced isotonic dialysate fluid, and was uncomplicated. Lavage led to striking immediate clinical improvement and no lavaged patient (Groups A and C) died during the first 10 days of treatment of pancreatitis. By contrast, 45% of deaths in nonlavaged patients (Group B and D) occurred during this early period, usually from cardiovascular or respiratory failure. Although lavage reduced mortality in subgroups of patients, ultimate overall survival was no affected (Group A, 83%; B, 84%; C, 33%; D,33%). Late peripancreatic abscesses caused most deaths in lavaged patients. These data show that peritoneal complications of severe acute pancreatitis and dramatically reduces early mortality. Lavage does not prevent the late local sequelae of peripancreatic necrosis.

Inheritance of apolipoprotein C-II deficiency with hypertriglyceridemia and pancreatitis.

Abstract: A study of the relatives of a patient with apolipoprotein C-II deficiency showed that the defect is inherited as an autosomal recessive trait. The kindred studied originated from an isolated population in which considerable inbreeding has occurred for 140 years. Seven homozygotes had marked fasting chylomicronemia and triglyceridemia, and lacked detectable apolipoprotein C-II by several assay methods. Five homozygotes had experienced one to many attacks of pancreatitis from as early as six years of age. Obligate heterozygotes had apolipoprotein C-II concentrations about 30 to 50 per cent of normal values and had normal plasma triglyceride concentrations. This metabolic defect should be considered in patients with markedly elevated plasma triglycerides who have apparent lipoprotein lipase deficiency, and usually also have pancreatitis.

Pancreatic Pseudocyst–Operative Strategy

Abstract: The experience with 131 patients with 157 pseudocysts is reported. One hundred and twenty patients with 146 pseudocysts underwent 165 operations. There were ten operative deaths (8.3%) three of which were not attributable to the pseudocyst or its operative management. Sixteen patients died six months to 14 years after operation. Deaths in six of the 16 patients were in part attributable to pancreatitis or complications of pseudocyst management. The operative mortality was highest in patients undergoing incision and drainage and cystoduodenostomy. Other factors influencing mortality unfavorably included postoperative gastrointestinal hemorrhage from a pseudocyst; rupture or fistulization of the cyst into the gastrointestinal tract if associated with hemorrhage, and evidence of common duct obstruction, or the location of cysts in the head or uncinate process of the pancreas. Visceral angiography should be performed on all patients with pseudocysts. The risk of massive gastrointestinal or intra-abdominal hemorrhage is highest in the 10% of patients having pseudoaneurysms associated with their pseudocysts. Incision and drainage of pseudocysts is associated with a high rate of recurrence of the cyst and continued pain. Incision and drainage should only be used if the cyst is infected, or the cyst wall is not mature enough to hold sutures. Cystogastrostomy and cystojejunostomy are the procedures of choice for mature cysts. The presence of a pseudoaneurysm visualized on preoperative visceral angiography is an indication for an excisional operation as are the presence of multiple cysts, compression of the common duct or duodenum by the cyst, evidence of left sided portal hypertension, recurrent cysts or evidence of chronic pancreatitis.

Carcinoembryonic antigen (CEA) levels in benign gastrointestinal disease states.

Abstract: Elevated circulating CEA levels occur in patients with benign gastrointestinal and hepatic disorders These are usually less than 10 ng/ml Of clinical importance is the influence of liver disease on the interpretation of CEA At least 50% of patients with severe benign hepatic disease have elevated CEA levels, most often active alcoholic cirrhosis, and also chronic active and viral hepatitis, and cryptogenic and biliary cirrhosis Patients with benign extrahepatic biliary obstruction may have increased plasma CEA, the highest in patients with co-existent cholangitis and especially liver abscess The liver appears to be essential for the metabolism and/or excretion of CEA Hence, liver work-up is needed to assess any patient with an elevated CEA A damaged liver may further augment elevated CEA levels due to cancer The increased circulating CEA observed in some patients with active ulcerative colitis tends to correlate with severity and extent of disease and usually returns to normal with remission CEA levels also may be mildly elevated in patients with pancreatitis and in adults with colonic polyps Smoking may contribute to the increased CEA levels seen in patients with alcoholic liver disease and pancreatitis Therefore, in interpreting mildy elevated circulating CEA levels in patients with GI tract diseases, one must consider benign as well as malignant etiologies

Total pancreatectomy of end-stage chronic pancreatitis.

Abstract: The metabolic consequences and the clinical results of total pancreatectomy for end-stage chronic pancreatitis are detailed. This experience, accumulated between the years 1952 and 1976, adds 26 cases to the world's literature, which now contains 53 cases reported singly or in small series. The patients were selected on the basis of far-advanced, incapacitating disease in three patients and the failure of 62 previous related operations in 23 patients. Total pancreatectomy was performed with a zero hospital mortality but with serious inhospital morbidity. After discharge, 24 patients required 55 hospital readmissions and 18 related surgical operations; 12 patients have died, five of unrelated causes. Of 14 living patients, five consider themselves to be in good to excellent condition, six in fair condition, and three in poor condition. Twelve thought they were improved over their preoperative state. Our estimate of the result in living patients was similar. In those 12 who died, only four had satisfactory results. The results are also evaluated relative to level of activity, presence of abdominal pain, use of narcotics, weight, alcohol consumption, and the efficiency of endocrine and exocrine replacement. In general, the procedure is effective for relief or amelioration of pain, but the patients' personalities preclude complete adaptation to the apancreatic state rehabilitation. A failure to thrive is the common denominator.

The endocrine pancreas in chronic pancreatitis. Immunocytochemical and ultrastructural studies.

Abstract: The endocrine pancreatic tissue from patients with severe primary chronic pancreatitis (n=6), secondary chronic pancreatitis due to duct obstruction by carcinoma (n=6) and non-diabetic, non-pancreatitic controls (n=4) was studied qualitatively and quantitatively using specific immunocytochemistry and electron microscopy. Grouping of variously sized islets in the sclerotic tissue (sclerosis islets), islet neoformation by ductuloinsular proliferation, and intrainsular fibrosis were the main qualitative findings. Immunocytochemical quantitation of the distribution of insulin (B), glucagon (A), somatostatin (D) and pancreatic polypeptide (PP) producing cells revealed a significant relative increase in the number of A cells and a decrease in the number of B cells of the sclerosis islets in primary chronic pancreatitis (B-44.1±9.3%:A-38.3±2.4%:D-8.6±5.1%:PP-4.6±4.1%) as well as in secondary chronic pancreatitis (B-38.0±14.3%:A-38.4±19.0%:D-9.1±5.8%:PP-14.5±23.4%) compared with controls (B-71.1±8.1%:A-24.3±5.5%:D-8.0±2.8%:PP-0.5±0.4%). The number of PP cells was significantly increased in primary chronic pancreatitis only. It is suggested that scarring of the exocrine pancreas affects islet composition, probably by impairment of the local circulation and of glucose diffusion, thus leading to reduction of the number and glucose sensitivity of B cells. The hyperplasia of A and PP cells appears to be a secondary phenomenon due to the loss of B cells.

Vasoative intestinal peptide and the watery diarrhea syndrome.

Abstract: A sensitive and specific radioimmunoassay for the detection of vasoactive intestinal peptide has been used to study patients with the watery diarrhea syndrome. In eleven patients the syndrome was associated with tumors, and plasma levels of vasoactive intestinal peptide were elevated. VIP levels returned towards normal in five treated patients coincident with amelioration of symptoms. Normal values were obtained in patinets with chronic pancreatitis, sprue, medullary carcinoma, Zollinger-Ellison Syndrome and laxative abuse. In six other patients with indistinguishable syndrome and no findings of tumor at laparotomy and autopsy, vasoactive intestinal peptide levels were normal. The results suggest that VIP may be the causative agent in patients with the watery diarrhea syndrome and tumors, but that an indistinguishable syndrome exists for which VIP is not the cause.

Visceral vessel erosion associated with pancreatitis. Case reports and a review of the literature.

Abstract: • Visceral artery erosion is an uncommon but disasterous complication of pancreatitis. When gastrointestinal bleeding or severe intra-abdominal hemorrhage is associated with pancreatitis and the usual sources of bleeding are not detected by endoscopy or barium studies, erosion of a visceral vessel should be suspected. We present nine cases and an additional 44 cases from previous reports are reviewed. A palpable abdominal mass was present in 59% of the patients; however, a pseudocyst was present in 78%. Arteriography was performed in 15 patients and the source of bleeding was evident in 14. The splenic artery was the most common site of bleeding, although the other branches of the celiac axis and the middle colic artery have been involved. Successful treatment consisted of ligation of the bleeding vessel and, if present, drainage of the pseudocyst. Depending on the location of the vessel and the pseudocyst, major resections may be necessary. When bleeding and the pancreatic inflammatory process involved the colon, ligation of the bleeding site, drainage of the area, and colostomy was the most successful form of treatment. ( Arch Surg 113:1438-1440, 1978)

Hereditary pancreatitis in England and Wales.

Abstract: Information from 72 patients from 7 families in England and Wales confirms that hereditary pancreatitis is inherited as an autosomal dominant conditions with limited penetrance. The degree of penetrance is approximately 80%. These patients have had recurrent attacks of abdominal pain starting from childhood or young adult life. The mean age of onset in the 7 families studied was 13.6 years. There were two peaks, with maximum numbers at 5 years and 17 years. The second peak was thought to represent genetically susceptible individuals having pain brought on by alcohol rather than representing evidence of genetic heterogeneity. Five of the 7 families had members with both childhood and adult ages of onset. Only 4 patients out of 72 had life-threatening disease and in the majority of cases the attacks of pain were of nuisance value only. Hereditary pancreatitis was implicated in only 1 patient's death and this was not definite. Patients appear to get better after a period of symptoms usually as they approach middle age, or after a severe attack. In older patients alcohol, emotional upsets, and fatty food appear to precipitate attacks. Pancreatic insufficiency (5.5%), diabetes mellitus (12.5%), pseudocysts (5.5%), and haemorrhagic pleural effusion are uncommon complications. Portal vein thrombosis occurred definitely in 2 patients and was suspected in 3 others. Carcinoma of the pancreas was not found in any of 72 patients studied in detail; however, 2 members from a family not visited personally had chronic pancreatitis and malabsorption going on to carcinoma. They may have suffered from a different disease. Genetic linkage information was too slight for many definite conclusions. However, there was no suggestion of linkage with any of the markers tested.

Infection of human pancreatic beta cell cultures with mumps virus.

Abstract: THE development of a diabetes-like syndrome in virus-infected animals, particularly in certain strains of mice infected with the M-variant of encephalomyocarditis (EMC) virus has recently been demonstrated1,2. The possibility that viruses might also cause diabetes mellitus in humans, particularly in juveniles, has been suggested periodically since the turn of the century1–6. The evidence, however, is largely circumstantial and comes from case reports showing a temporal relationship between the onset of certain viral infections, particularly mumps, and the subsequent development of diabetes. Although it has been known for some time that pancreatitis may be a complication of mumps7–10, specific involvement of the beta cells has never been demonstrated. Since it is not feasible to obtain pancreatic biopsies during the course of viral infections, we initiated experiments to determine if human pancreatic beta cells grown in culture were susceptible to mumps virus. We have used a double-label antibody technique, using fluorescein labelled anti-mumps antibody and rhodamine labelled anti-insulin antibody, and we show here for the first time that human beta cells can be infected with mumps virus.

Cholestasis and lesions of the biliary tract in chronic pancreatitis.

Abstract: The occurrence of jaundice in the course of chronic pancreatitis has been recognised since the 19th century\" 2. But in the early papers it is uncertain whether the cases were due to acute, acute relapsing, or to chronic pancreatitis, or even to pancreatic cancer associated with pancreatitis or benign ampullary stenosis. With the introduction of endoscopic retrograde cholangiopancreatography (ERCP), there has been a renewed interest in the biliary complications of chronic pancreatitis (CP). However, papers published recently by endoscopists have generally neglected the cholangiographic aspect of the lesions and are less precise and less well documented than papers published just after the second world war, following the introduction of manometric cholangiography3-5. Furthermore, the description of obstructive jaundice due to chronic pancreatitis, classical 20 years ago, seems to have been forgotten until the recent papers.

Is nasogastric suction necessary in acute pancreatitis

Abstract: Fifty-eight patients with mild to moderately severe acute pancreatitis were randomly allocated to treatment with or without nasogastric suction (27 and 31 patients respectively). Intravenous fluids and pethidine hydrochloride were also given. The two groups were comparable clinically at the start of the study. There were no differences between the two groups in the mean duration of the following features: abdominal pain or tenderness; absence of bowel movements; raised serum amylase concentration; time to resumption of oral feeding; and days in hospital. Prolonged hyperamylasaemia (serum amylase greater than 0.33 mU/l) occurred in one patient in the suction group and in three patients in the non-suction group. A mild recurrence of abdominal pain after resumption of oral feeding occurred in three patients in the suction group and in two patients in the non-suction group. Two patients in the suction group developed overt consumption coagulopathy and two others pulmonary complications. No patient in the non-suction group had complications. The findings suggest that most patients with mild to moderately severe acute pancreatitis do not benefit from nasogastric suction. The procedure should be elective rather than mandatory in treating this condition.

Glucagon therapy in acute pancreatitis. Report of a double-blind trial.

Abstract: The results of a double-blind trial of glucagon in 69 patients with acute pancreatitis are reported. In a subgroup of 59 patients statistical analysis showed no significant differences between the glucagon-treated (n = 29; 2 X 5 mg protamine-zinc glucagon intramuscularly per day) and the placebo-treated (n = 30) subjects for the following data: duration of pain left spontaneously and induced by palpation, amounts of analgesics and antispasmodics required by the patients, duration of hospital stay, amylase activities in serum and 24 hour urine collections. Mortality rates did not differ significantly between the glucagon-treated and the placebo-treated subjects in the total group of 69 patients and in the two subgroups of patients who were treated conservatively (n = 59) and those who underwent laparotomy because of severe peritonitis (n = 10). From the results of this study it is concluded that favourable effects of glucagon upon the course of acute pancreatitis--if they do exist--are not significant.

Diabetes and the gut.

Abstract: The pathophysiology of impaired gastrointestinal function in both chronic diabetes1' 2, and acute ketoacidosis3, remains undefined, although several mechanisms have been implicated. These include autonomic neuropathy4, microangiopathy5, changes in insulin and glucagon release, and acute metabolic disturbance. In recent years various new gastrointestinal hormones have been described6' 7, although their physiological importance remains to be determined8. It is likely that both the chronic, and acute, metabolic changes found in diabetes will modify the release of these hormones and alter their effects on the gut. However, at the present time there are no studies of gut hormone levels in diabetics with gastrointestinal complications and the pathophysiological significance of these substances remains ill-defined. This review will consider both the acute and chronic effects of diabetes mellitus on the gastrointestinal tract alone and will largely be confined to human data.

Sensitivity of Pancreatic Ultrasonography in the Detection of Pancreatic Disease

Abstract: Pancreatic ultrasonography was correct 87% of the time in separating patients with a normal pancreas from those with an abnormality. Of those patients felt to have a normal pancreas by ultrasonography, only 81 % were ultimately found normal. In this group, errors occurred primarily in patients with chronic pancreatitis. An abnormal pancreatic ultrasonogram is significant and usually indicates disease; ultrasonography correctly identified 94% of those patients ultimately found to have an abnormal pancreas.

Hemosuccus pancreaticus (hemoductal pancreatitis): gastrointestinal hemorrhage due to rupture of a splenic artery aneurysm into the pancreatic duct.

Abstract: • A patient with recurrent upper gastrointestinal bleeding was found to have pancreatitis and a pseudoaneurysm of the splenic artery that communicated with the pancreatic duct. Similar pathology noted in ten other patients found in an extensive review of the literature suggest that this rare entity must be considered in the diagnosis of gastrointestinal hemorrhage of obscure origin. In this collected experience, the combination of recurrent left upper quadrant pain, a history of pancreatitis, and recurrent bouts of gastrointestinal bleeding of obscure origin were usually present in those patients who were found to have a splenic artery aneurysm as the source of the blood loss. Distal pancreatectomy with resection of the splenic artery aneurysm is curative. ( Arch Surg 113:751-753, 1978)

A radioimmunoassay for measurement of human pancreatic secretory trypsin inhibitor in different body fluids.

Abstract: A radioimmunoassay for measurement of human pancreatic secretory trypsin inhibitor in nanogram quantities has been developed. The sensitivity of the assay now permits examination of the inhibitor content of various body fluids, wherein other methods exhibit serious short-comings. In healthy blood donors the serum level was 8.1 microgram/l. In patients with acute pancreatitis levels as high as 320 microgram/l have been measured, and patients who underwent endoscopic retrograde cholangiopancreatography showed an elevated inhibitor level in serum immediately after the examination without any clinical signs of disease, the highest registered value being 128 microgram/l. In peritoneal lavage fluid from patients with severe acute pancreatitis levels of 5-304 microgram/l have been measured. In urine the inhibitor level is about 14 microgram/l in healthy persons. The urine from one patient with proteinuria of glomerulo-tubular type contained 380 microgram/l.

The Ageing Gut: A Study of Intestinal Absorption in Relation to Nutrition in the Elderly

Abstract: This study was designed to assess the functional efficiency of the ageing small intestine and the possible role of malabsorption in old people with nutritional deficiencies. Fifty subjects aged 65 to 92 years were studied, of whom 33 presented with anaemia, chronic diarrhoea or bone pains, and 17 were apparently healthy 'controls' with no relevant symptoms. Tests of intestinal function included blood xylose and iron absorption curves, a double isotope Schilling test, faecal fat, urinary indican and small bowel radiology, with duodenal aspiration and jejunal biopsy in some cases. On the basis either of steatorrhoea or at least two other abnormal parameters of absorption, there were 15 cases of malabsorption. Thirteen of these had symptoms but two were 'controls'. Four of these had duodenal diverticulosis, two had the post-gastrectomy syndrome, and one had calcific pancreatitis. Malabsorption in the remaining eight cases was not fully explained. The age range of this last group was 72--86 years; one of them had a contaminated small bowel and two showed some evidence of pancreatic insufficiency. Malabsorption emerged as a significant cause of low levels of serum iron, haemoglobin and calcium. The blood xylose test is a useful screening procedure for intestinal malabsorption in old age, but full evaluation calls for investigation of pancreatic function.

Acute cholestasis, hepatic failure, and fatty liver in the alcoholic.

Abstract: Three alcoholic patients are described who presented with acute cholestasis and liver cell failure. In each patient the liver biopsy showed severe fatty change with cholestasis, but without typical alcoholic hepatitis. There was no evidence of extra-hepatic biliary obstruction, although one patient had chronic pancreatitis. Two of the three patients died of hepatic failure, but the third recovered and has remained well while abstaining from alcohol.

Complications of Corticosteroid Therapy

Abstract: • The complications of corticosteroid therapy in children are protean. Perhaps the most important of these are adrenal insufficiency after withdrawal of steroids, immunosuppression, and growth failure. The physician who is caring for a child receiving corticosteroids must be aware of these common complications as well as the many less frequent side effects, such as cataracts, pseudotumor cerebri, pancreatitis, and steroid myopathy, to name a few. In all children, the risk of using corticosteroids should be weighed carefully before therapy with these agents is begun. ( Am J Dis Child 132:806-810, 1978)

Computed tomography in pancreatic disease.

Abstract: Computed tomography (CT) of the pancreas has been evaluated in 50 patients with established exocrine pancreatic disease and 20 patients without pancreatic disease. Increase in size, irregularity in outline and heterogeneity of composition of the pancreas implied disease but were in no way specific to any particular disease entity. In acute pancreatitis, following complete resolution, the pancreas appeared normal whereas incomplete resolution was associated with non-specific swelling and heterogeneity of density. The extent and location of pseudocysts could be accurately delineated. In chronic pancreatitis, duct calculi, duct dilatation and large intrapancreatic cysts aided the differentiation between focal enlargement due to chronic pancreatitis and expansion due to cancer. Hepatic metastases and abnormalities of the biliary system seen in association with cancer further aided this differentiation.

Cutaneous manifestations of pancreatic diseases.

Abstract: An awareness of the cutaneous signs of diseases of the pancreas is extremely valuable. They alert the astute examiner to several life-threatening problems that result from both benign and malignant islet cell tumors, adenocarcinomas of the pancreas, and pancreatic endocrine and inflammatory diseases. Many of the cutaneous manifestations of pancreatic disease are discussed in detail, with emphasis on both the clinical presentation and pathogenesis.