Showing papers on "Pancreatitis published in 1989"

6-Mercaptopurine in the management of inflammatory bowel disease: short- and long-term toxicity.

Abstract: We assess toxicity related to 6-mercaptopurine in the treatment of inflammatory bowel disease by reporting our experience with 396 patients (120 patients with ulcerative colitis, 276 with Crohn disease) observed over 18 years. Follow-up data for a mean period of 60.3 months were obtained for 90% of the patients. Toxicity directly induced by 6-mercaptopurine included pancreatitis in 13 patients (3.3%), bone marrow depression in 8 (2%), allergic reactions in 8 (2%), and drug hepatitis in 1 (0.3%). These complications were reversible in all cases with no mortality. Most cases of marrow depression occurred earlier in our experience, when the initial drug doses used were higher. Infectious complications were seen in 29 patients (7.4%), of which 7 (1.8%) were severe, including one instance of herpes zoster encephalitis. All infections were reversible with no deaths. Twelve neoplasms (3.1%) were observed, but only 1 (0.3%), a diffuse histiocytic lymphoma of the brain, had a probable association with the use of 6-mercaptopurine. Our data, showing a low incidence of toxicity in 396 patients, coupled with the previously demonstrated efficacy of 6-mercaptopurine in the treatment of inflammatory bowel disease, indicate that the drug is a reasonable alternative in the management of patients with intractable inflammatory bowel disease.

Duodenum-preserving resection of the head of the pancreas in severe chronic pancreatitis. Early and late results.

Abstract: In 128 patients with severe chronic pancreatitis and inflammatory enlargement of the head of the pancreas, a duodenum-preserving resection of the pancreatic head was performed. Median post-operative hospitalization was 15.5 days, and the frequency of reoperation was 5.5%. One patient died during the early post-operative phase, and hospital mortality amounted to 0.8%. After a median follow-up period of 3.6 years (range of 7 months to 16 years), six of 127 patients died (late mortality of 4.7%). Seventy-seven per cent of the patients were completely free of abdominal pain, 67% returned to their former occupations. During the late follow-up period, the glucose metabolism was unchanged in 80.7% of the patients, in 13.7% it deteriorated, and in 5.5% it improved permanently; 80% of the patients experienced a marked increase in weight averaging 8.7 kg. Compared with the Whipple procedure, the duodenum-preserving resection of the head of the pancreas spares the patient with chronic pancreatitis a gastrectomy, duodenectomy, and resection of the extrahepatic biliary ducts. In terms of a subtotal resection, the limited operative intervention at the head of the pancreas and the preservation of the duodenum explain the low early and late postoperative morbidity and mortality.

Acute pancreatitis and normoamylasemia. Not an uncommon combination.

Abstract: A consecutive series of 352 attacks of acute pancreatitis (AP) was studied prospectively in 318 patients. AP was ascertained by contrast-enhanced CT scan in all but four cases in which diagnosis was made at operation or autopsy. Sixty-seven of these cases (19%) had normal serum amylase levels on admission (i.e., less than 160 IU/L, a limit that includes 99% of control values), a figure considerably higher than generally admitted. When compared to AP with elevated serum amylase, normoamylasemic pancreatitis was characterized by the following: (1) the prevalence of alcoholic etiology (58% vs. 33%, respectively, p less than 0.01), (2) a greater number of previous attacks in alcoholic pancreatitis (0.7 vs. 0.4, p less than 0.01); and (3) a longer duration of symptoms before admission (2.4 vs. 1.5 days, p less than 0.005). In contrast AP did not appear to differ significantly in terms of CT findings, Ranson's score, and clinical course, when comparing normo- and hyperamylasemic patients, although there was a tendency for normoamylasemic patients to follow milder courses. Serum lipase was measured in 65 of these normoamylasemic cases and was found to be elevated in 44 (68%), thus increasing diagnostic sensitivity from 81% when amylase alone is used to 94% for both enzymes. A peritoneal tab was obtained in 44 cases: amylase concentration in the first liter of dialysate was greater than 160 IU/L in 24 cases (55%), and lipase was greater than 250 U/L in 31 cases (70%). Twelve of these 44 cases had low peritoneal fluid and plasma concentrations for both enzymes. Thus little gain in diagnostic sensitivity was obtained when adding peritoneal values (96%) to serum determinations. AP is not invariably associated with elevated serum amylase. Multiple factors may contribute to the absence of hyperamylasemia on admission, including a return to normal enzyme levels before hospitalization or the inability of inflamed pancreases to produce amylase. Approximately two thirds of cases with normal amylasemia were properly identified by serum lipase determinations. AP does not appear to behave differently when serum amylase is normal or elevated, and should therefore be submitted to similar therapeutic regimens in both conditions.

Intraductal papillary neoplasms of the pancreas. A clinicopathologic study of six patients.

Abstract: A clinicopathologic study was conducted on six patients with intraductal papillary neoplasms of the pancreas. The patients were of both sexes and their ages ranged from 64 to 79 years. Three patients had a long history of symptoms mimicking chronic pancreatitis. The tumors involved the main pancreatic duct in the head-body region either diffusely or focally. Histologic examination showed papillary proliferations of well-differentiated, mucus-secreting cells that occasionally stained for carcinoembryonic antigen (CEA) and carbohydrate antigen (CA 19-9). The proliferations filled the main pancreatic duct, and extended into smaller ducts in some cases. In three patients, the lesions contained foci of pronounced to severe cellular atypia and carcinoma in situ. None of our series or any similar cases reported in the literature has shown invasion into peripancreatic tissue, metastasis, or tumor recurrence after pancreatectomy. Because of their favorable prognosis, intraductal papillary neoplasms should be considered low-grade malignancies that must not be confused with the common ductal adenocarcinoma.

Neutrophil-dependent, oxygen-radical mediated lung injury associated with acute pancreatitis.

Abstract: Cerulein-induced acute pancreatitis in rats is associated with a reversible lung injury that is characterized by alveolar capillary endothelial-cell injury, increased microvascular permeability, interstitial edema formation, and intraalveolar hemorrhage and fibrin deposition. The role of mediators in this injury was analyzed using gravimetric data, microvascular permeability indices, electron microscopy, and a quantitative morphometric analysis. Neutrophil depletion induced by a specific antibody was highly protective against lung injury. Interruption of the complement pathway (using low dose Naja naja cobra venom factor) also protected against lung injury. Catalase and superoxide dismutase were also protective. The iron chelator deferoxamine and the hydroxyl radical scavenger, dimethylsulfoxide, were not protective against acute lung injury. These data suggest that complement, neutrophils, and neutrophil-derived (H2O2-dependent) oxygen products mediate lung injury that occurs secondary to cerulein-induced pancreatitis. In contrast to other models of neutrophil-dependent, oxygen-radical-mediated lung injury, this lung injury does not appear to be an iron-dependent and hydroxyl-radical mediated injury. We postulate that the process of acute pancreatitis leads to complement activation followed by neutrophil recruitment, sequestration, and adherence to alveolar capillary endothelial cells. Ultimately lung injury appears to result from local endothelial-cell injury secondary to neutrophil-generated oxygen products that may be myeloperoxidase dependent.

Pancreatic duct obstruction in rabbits causes digestive zymogen and lysosomal enzyme colocalization.

Abstract: The pancreatic duct of anesthetized rabbits was cannulated and, in some animals, flow of pancreatic exocrine secretions was blocked by raising the cannula to a vertical position. Blockage for 3-7 h caused a rapid and significant rise in serum amylase activity and an increase in amylase activity within the pancreas. The concentration of lysosomal enzymes in the pancreas was not altered but they became redistributed among subcellular fractions and, as a result, an increased amount was recovered in the 1,000-g, 15-min pellet, which was enriched in zymogen granules. Immunofluorescence studies indicated that lysosomal enzymes become localized within organelles which, in size and distribution, resemble zymogen granules. They also contain digestive enzyme zymogens. Blockage of pancreatic secretions also caused lysosomal enzyme-containing organelles to become more fragile and subject to in vitro rupture. These changes noted after short-term pancreatic duct obstruction are remarkably similar to those previously noted to occur during the early stages of diet and secretagogue-induced experimental pancreatitis, observations that have suggested that colocalization of digestive enzyme zymogens and lysosomal hydrolases might result in intracellular digestive enzyme activation and be an important early event in the evolution of those forms of experimental acute pancreatitis.

Chronic pancreatitis: reassessment with current CT.

Abstract: A retrospective analysis was performed of contrast material-enhanced current-generation computed tomographic (CT) examinations in 56 patients with documented chronic pancreatitis. Dilatation of the main pancreatic duct was seen in 68% of cases, parenchymal atrophy in 54%, pancreatic calcifications in 50%, fluid collections in 30%, focal pancreatic enlargement in 30%, biliary ductal dilatation in 29%, and alterations in peripancreatic fat or fascia in 16%. The relatively small proportion of examinations in which no abnormalities were observed, 7%, differs from that in early reports, as does the absence of generalized pancreatic enlargement. Pancreatic ductal dilatation and parenchymal atrophy were notably more prevalent than reported previously. Nine of the 17 patients with focal pancreatic enlargement had calculi within the mass, which suggested benign disease; of the eight other patients, two of whom had coexistent carcinoma, this finding was absent and the masses were considered indeterminate at CT.

Idiopathic Recurrent Pancreatitis An Approach to Diagnosis and Treatment

Abstract: The cause of recurrent acute pancreatitis can be identified in the majority of patients. A small group of patients in whom an etiological association is not obvious is characterized as idiopathic recurrent pancreatitis (IRP). During the last seven years, we used endoscopic retrograde cholangiopancreatography (ERCP) and sphincter of Oddi (SO) manometric pressure studies to investigate 116 patients initially diagnosed as IRP. Forty-four of the 116 patients were found to have a demonstrable cause of their pancreatitis. Appropriate therapeutic intervention was carried out in 43 of these patients with a favorable outcome in the majority of patients noted during long-term follow-up.

Prediction of pancreatic necrosis by dynamic pancreatography.

Abstract: Parenchymal necrosis has recently been recognized as the principal determinant of the incidence of secondary infection in acute pancreatitis. Because secondary infection of pancreatic necrosis accounts for more than 80% of all deaths from acute pancreatitis, a method for determining the presence or absence of parenchymal necrosis would offer considerable prognostic and therapeutic information. Thirty seven patients with unequivocal acute pancreatitis and five normal controls were prospectively studied with intravenous bolus, contrast-enhanced computed tomography (dynamic pancreatography). In the absence of pancreatic necrosis, there were no significant differences in parenchymal enhancement between any of the following patient groups: controls (5), uncomplicated pancreatitis (20), pancreatic abscess (7), or peripancreatic necrosis (4)(p less than 0.05). On the other hand, pancreatic parenchymal enhancement was significantly reduced or absent in all six patients with segmental or diffuse pancreatic necrosis (p less than 0.05). Postcontrast pancreatic parenchymal enhancement was also found to be inversely correlated with the number of Ranson signs (p less than 0.001). Dynamic pancreatography offers prognostic information and is a safe and reliable technique for predicting the presence or absence of pancreatic parenchymal necrosis.

Endoscopic Placement of Pancreatic Stents and Drains in the Management of Pancreatitis

Abstract: Although widely used in the biliary tree, little data is available on endoscopic placement of stents or drains within the pancreas. This report describes 17 patients, nine with acute relapsing pancreatitis and eight with chronic pancreatitis, who had drain or stent placement for hypertensive pancreatic duct (PD) sphincter, dominant ductal stenosis, duct disruption, or pseudocyst. Two patients have subsequently undergone surgery, and six other patients continue long-term stent placement with marked reduction of chronic pain or attacks of recurrent pancreatitis. All six pseudocysts resolved, although one recurred and required surgery. It is concluded that pancreatic drains or stents may obviate the need for surgery, temporize before definitive therapy, or direct a subsequent surgical procedure.

New modalities for treating chronic pancreatitis.

Abstract: Over the last few years, a new method, neither medical nor surgical, has been developed for treating often difficult-to-treat chronic pancreatitis. In the case of obstructive pancreatitis, endoscopy permits both drainage and calculus extraction. Even encrusted concrements and calcifications can be removed from the pancreatic duct with the aid of extracorporeal shockwave lithotripsy. The first aim is to relieve pain by restoring a free flow of secretion. Perhaps the use of endoscopic treatment in the early stages will break the vicious circle of chronic inflammation and ultimate gland destruction.

Antibiotics in acute pancreatitis: Current status and future directions

Abstract: Infectious complications currently account for 80 percent of deaths from acute pancreatitis. The adjunctive role of antibiotics in the prevention and treatment of secondary pancreatic infections has received insufficient attention. Randomized clinical studies of effective antibiotics for prophylaxis or empiric therapy of pancreatic infections do not currently exist. In their absence, it is not known whether prophylactic antibiotics are useful in patients with acute pancreatitis. Until such studies are available, if antibiotics are to be used, their choice must be based upon indirect criteria: the ability of the antibiotic to effectively penetrate pancreatic tissue and juice, knowledge of the most common pancreatic pathogens, and the ability of the antibiotic to exceed the in vitro concentration (MIC-90) in pancreatic juice for the common pathogens. Recognition of the limited state of knowledge regarding antibiotics in acute pancreatitis may stimulate future investigations.

Pancreatoduodenectomy with occlusion of the residual stump by Neoprene injection.

Abstract: Pancreatojejunal anastomosis disruption still represents the main postoperative complication after pancreatoduodenectomy. In this study, a technique of occlusion of the residual pancreatic stump instead of pancreatojejunal anastomosis is proposed. Between March, 1981 and August, 1987, we performed 51 pancreatoduodenectomies, using Neoprene ® injection in the Wirsung duct, for carcinoma of the pancreatic head (28 cases), ampullary carcinoma (12 cases), islet cell carcinoma (5 cases), and chronic pancreatitis (6 cases). We observed a 33.3% overall morbidity, with a 5.8% operative mortality. The complications observed seemed not to be related to the technique of pancreatic stump occlusion, except for 2 pancreatic fistulas which spontaneously resolved. Abdominal ultrasound and computed tomography scan performed during the follow-up did not show any significant morphological alteration of the residual stump. Pancreatic endocrine function was assessed in 10 patients by evaluating blood glucose, plasma insulin and plasma glucagon levels both fasting and after oral glucose, and intravenous arginine infusion. These tests were performed before surgery and 15 days, 6 months, 1, 2, and 3 years after surgery. The results showed that 60% of the patients had impaired glucose tolerance before surgery and the percentage did not significantly change up to 3 years later (75%). No patient developed diabetes mellitus, and only 1 patient progressed from a normal to an impaired glucose tolerance. In conclusion, intraductal injection of Neoprene ® after pancreatoduodenectomy seems to be a safer procedure compared to pancreatojejunal anastomosis and does not induce a postsurgical diabetes.

Experimental pancreatitis is mediated by low-affinity cholecystokinin receptors that inhibit digestive enzyme secretion

Abstract: Rats infused with a supramaximally stimulating dose of the cholecystokinin (CCK) analog caerulein develop acute edematous pancreatitis. Using CCK-JMV-180, a recently developed CCK analog that acts as an agonist at high-affinity CCK receptors but antagonizes the effect of CCK at low-affinity receptors, we have determined that caerulein induces pancreatitis by interacting with low-affinity CCK receptors. Those low-affinity receptors mediate CCK-induced inhibition of digestive enzyme secretion from the pancreas. Our observations, therefore, suggest that this form of experimental pancreatitis results from the inhibition of pancreatic digestive enzyme secretion.

Role of serum pancreatic enzyme assays in diagnosis of pancreatic disease.

Abstract: The serum behavior of amylase, pancreatic isoamylase, lipase, trypsinogen, and elastase 1 was studied in 145 patients with pancreatic disease and in 66 patients with abdominal pain of nonpancreatic origin, for the purpose of evaluating the relative diagnostic utility of their assays. In 34 patients with acute pancreatitis, serum lipase, trypsinogen, and elastase 1 were elevated in all 34, pancreatic isoamylase in 33 (97%) and amylase in 30 (88%). Ten of these acute pancreatitis patients were followed sequentially for seven days: the variations in their serum enzyme levels were parallel, although the lipase, trypsinogen, and particularly the elastase 1 elevations persisted longer than did those of amylase and pancreatic isoamylase. Among the patients with chronic pancreatitis, either in painful relapse (N=19) or with pancreatic cysts (N=15), the respective percentages of enzymes elevations were: 79 and 80% for elastase 1, 68 and 67% for trypsinogen, 63 and 73% for pancreatic isoamylase, 58 and 60% for lipase, 53 and 60% for amylase. In the 52 chronic pancreatitis patients studied during clinical remission, serum enzyme behavior varied greatly, and a majority of the assays (60%) were normal; even in the case of severe pancreatic exocrine insufficiency, normal as well as abnormally high and low enzyme values were seen. Highly variable enzyme behavior was also seen in the 40 patients with pancreatic cancer, and elastase I was the most frequently (35%) elevated enzyme in this group as well. Among the patients with abdominal pain of nonpancreatic origin, abnormally high enzyme levels were present in percentages ranging from 6% for lipase to 21% for trypsinogen. These data indicate that serum pancreatic enzyme assays are of value in establishing the diagnosis of acute pancreatitis and a relapse or cystic complication of chronic pancreatitis. In the case of pancreatic cancer or of chronic pancreatitis in clinical remission, the diagnostic role of the studied enzymes is rather limited.

Clinical and histopathological appraisal of preoperative irradiation for adenocarcinoma of the pancreatoduodenal region.

Abstract: A retrospective review to elucidate the rationale of preoperative irradiation was made on 18 carcinomas of the head of the pancreas area. After 50 Gy/25 fractions of 10 MV X-ray was given, all 18 tumors decreased from 3.3 +/- 0.8 cm to 2.0 +/- 0.7 cm. At the surgical operation, 16 patients (89%) received pancreatic resection, without operative death. Histologically, in 13 of these 16 cases, the population of severely degenerative cancer cells (SDCC) was more than 1/3 of all cancer cells, and SDCCs were likely to locate at the periphery (advancing point of carcinoma). These histological patterns were considered as favorable to improve the operative curability. However, in the remaining three cases, the SDCC population was less than 1/3. In addition, nonaffected (i.e., viable) cancer cells were detected at the periphery, and this is an extremely adverse condition for subsequent surgery. Chronic pancreatitis in the noncancerous area was present in these three cases, but not in the 13 cases. Therefore, the most significant factor that predicts the radioresistance especially at the periphery of the carcinoma was considered to be coexisting chronic pancreatitis.

Hyperamylasemia after cardiac surgery. Incidence, significance, and management.

Abstract: The significance of hyperamylasemia and its relationship to pancreatitis after cardiac surgery is controversial. Three hundred consecutive patients undergoing cardiopulmonary bypass were prospectively studied to determine the incidence and significance of postoperative hyperamylasemia. Ninety-six of three hundred patients (32%) developed hyperamylasemia. Fifty-six patients (19%) were classified as having isolated hyperamylasemia because they were asymptomatic and had normal serum lipase. Thirty-two patients (10.7%) had subclinical pancreatitis defined as elevation of serum amylase and lipase or pancreatic isoamylase. Many of these patients had mild gastrointestinal symptoms that were self-limited. Eight patients (2.7%) had overt pancreatitis documented by clinical findings, biochemical abnormalities, and computed tomography (CT) scan or autopsy. Isoamylase analysis demonstrated that isolated hyperamylasemia usually originated from nonpancreatic sources. However, hyperamylasemia occurring in conjunction with abdominal signs and symptoms or elevated serum lipase was almost always pancreatic in origin. Patients with hyperamylasemia had a significantly higher mortality rate (seven of 96 patients, 7.5%) than those with normal serum amylase (two of 204 patients, 0.9%) (p less than 0.01) even when the amylase was nonpancreatic in origin (five of 56 patients, 9%). The reason that nonpancreatic hyperamylasemia is associated with increased postoperative mortality is not established but may represent a variety of metabolic aberrations or tissue injuries. It is concluded that 1) hyperamylasemia after cardiopulmonary bypass is a marker of potential clinical importance, and 2) pancreatitis in this setting is more common than previously recognized and is a potentially lethal complications. Successful treatment depends on early diagnosis and aggressive treatment.

Activation of proteases in cerulein-induced pancreatitis.

Abstract: Summary The activation of zymogen proteases and lysosomal enzyme cathepsin B in the pancreas was investigated in cerulein-induced pancreatitis in rats. Acute pancreatitis was induced by two intraperitoneal injections of 40 pg/kg of body weight of cerulein at intervals of 1 h. After the first cerulein injection, the active trypsin and elastase contents in the pancreas tissues significantly increased, and reached the highest level at 3 h after the first injection, followed by peaks at 5 h in the serum amylase and lipase levels and the pancreas wet weight. Cathepsin B contents in pancreas tissues showed a parallel increase with active zymogen enzymes during the first 3 h of pancreatitis. These findings may suggest that the intracellular activation of trypsinogen is an important step in the development of cerulein-induced acute pancreatitis and that cathepsin B plays a role in the activation of trypsinogen in pancreatic acinar cells.

Total parenteral nutrition and alternate energy substrates in treatment of severe acute pancreatitis.

Abstract: The use of total parenteral nutrition (TPN) in the treatment of 73 patients with acute severe pancreatitis was prospectively studied during a two year period. Patients were divided into three groups on the basis of calorie substrate used. Glucose and twice weekly lipid infusion (glucose based) were used in 60 per cent; 27 per cent required daily lipid infusion (lipid based), and 13 per cent received no lipid because of pre-existing hyperlipemia or thrombocytopenia (no lipid). Nutritional indices (albumin, transferrin and total lymphocyte count) were initially abnormal in more than 80 per cent of patients, and 50 per cent had three or more of Ranson's criteria. After TPN, 81 per cent had improved nutritional indices, and none had hypertriglyceridemia or aggravation of pancreatitis develop. Patients who received lipid based or no lipid had higher insulin requirements (p less than 0.01) than those receiving mainly glucose. Mortality was increased tenfold (2.5 versus 21.4 per cent, p less than 0.01) in patients who did not achieve positive nitrogen balance. We conclude that TPN, either lipid or glucose based, is a safe and effective therapy to reverse the malnutrition of acute pancreatitis and that failure to achieve positive nitrogen balance is associated with increased mortality.