Search

Gastrointestinal bleeding is a frequent complication in hemodialysis patients; angiodysplasia is a potential cause, with a higher incidence in uremic patients. We describe a case of severe anemia (Hemoglobin up to 3.5 g/dl) secondary to diffuse angiodysplastic lesions in a hemodialysis patient with mixed connective tissue disease. The case is characterised both by the severity of the clinical picture (extension and entity of angiodysplastic lesions, frequency of bleeding episodes) and by the patient's religious faith which made her reject blood transfusions. We underline the efficacy of estrogen-progesterone therapy in view of the modest results obtained with other therapeutic strategies on bleeding.

This study assessed the diagnostic accuracy of fecal elastase 1 in chronic pancreatitis. Fifty-three healthy subjects, 44 patients with chronic pancreatitis (22 severe, 13 moderate, and 9 mild), and 43 patients with nonpancreatic digestive disease were studied. Elastase 1 concentration was determined on a small sample of feces using a commercially available kit. Fecal chymotrypsin was also measured. With a cutoff level of 190 microg/g, all healthy controls except one (98.1%), and the majority of patients with nonpancreatic digestive diseases (40 of 43; 93.0%) had elastase values above this limit. Among the 44 patients with chronic pancreatitis, 34 (77.3%) had pathological values: all 22 (100%) with severe disease, 10 of 13 (76.9%) with moderate disease and 2 of 9 (22.2%) with mild disease. Chymotrypsin values were pathological in 25 of 44 (56.8%) patients with chronic pancreatitis: 17 of 22 (77.2%) with severe pancreatitis, 7 of 13 (53.8%) with moderate pancreatitis, and 1 of 9 (11.1%) with mild disease. The specificity was 95.8% for elastase 1 and 85.4% for chymotrypsin. The difference both in sensitivity and specificity of the two enzymes was statistically significant (P0.05). Fecal elastase 1 has a high sensitivity, superior to that of fecal chymotrypsin, in the diagnosis of chronic pancreatitis. For its simplicity and rapidity, it could represent the tubeless test of choice in chronic pancreatitis.

We evaluated a new continuous colorimetric method for serum lipase determination based on the use of a 1,2-diglyceride as substrate and a specific 2-monoglyceride lipase. This test was compared with a turbidimetric assay and also with serum alpha-amylase and pancreatic isoamylase determinations. We studied 32 patients with acute pancreatitis, 27 with chronic pancreatitis in acute painful relapse, 19 with pancreatic cancer, 44 with other digestive diseases, 53 with end-stage renal disease, and 102 healthy controls. The results of the new test were closely correlated with those of the turbidimetric method (r = 0.96). Sensitivity of the new method was elevated (100%): it was the same as that of the turbidimetric method, but slightly higher than that of alpha-amylase and pancreatic isoamylase determinations (93.7 and 96.9%, respectively). Specificity was 95.5%, i.e. higher than that observed using the other tests (86.4, 84.1 and 88.6% for lipase turbidimetric assay, amylase, and pancreatic isoamylase determinations, respectively). The results demonstrate that this new lipase assay is a sensitive, specific test for the diagnosis of acute pancreatitis.

Serum amylase, pancreatic isoamylase, lipase, trypsinogen and elastase-1 were measured in 100 consecutive patients who were emergency admissions to a surgical department, and in 27 selected patients with proven acute pancreatitis who served as controls. The final diagnoses in the 100 patients of the study group were: acute pancreatitis in eight patients, other digestive diseases in 87, and urogenital tract diseases in five. In the control group, pancreas-specific enzymes were abnormally high in all patients and amylase in 26 out of 27. In the study group, all enzymes were markedly high in all eight patients with acute pancreatitis. In the remaining 92 patients, serum amylase was abnormally high in seven, and at least one pancreatic enzyme was elevated in 16. These elevations were generally mild. The diagnostic efficiency, i.e., the percentage of patients correctly classified, was 96% for pancreatic isoamylase and lipase, 93% for amylase, 91% for elastase-1, and 84% for trypsinogen. We conclude that serum lipase turbidimetric assay is the most suitable test for emergency diagnosis of acute pancreatitis, because it is highly sensitive and specific and simply and quickly performed.

A method has recently been developed for measuring serum pancreatic (P) isoamylase, using two monoclonal antibodies specific for salivary isoamylase. We performed this test on 67 healthy controls and 133 patients: 15 with acute pancreatitis, 53 with chronic pancreatitis (20 during painful relapse and 33 in clinical remission), 18 with pancreatic cancer, 41 with nonpancreatic disease with abdominal pain, five with macroamylasemia, and one with total pancreatectomy. Results were compared with those of a wheat germ inhibition method and with electrophoresis on cellulose acetate. A close correlation was found between the results of immunoinhibition assay and those of the other two tests. All patients with acute pancreatitis had abnormally high values in all three tests. In the group with chronic pancreatitis studied during painful relapse, 16 had an increase in P-isoamylase, as determined with the immunoinhibition assay, 13 with the wheat germ inhibition test, and 15 with electrophoresis. In the group with chronic pancreatitis in clinical remission, we found low values in one patient, by immunoinhibition assay, but found low values in 17 and 19 patients by wheat germ inhibition and electrophoresis, respectively. Low P-isoamylase values corresponded to a severe exocrine pancreatic insufficiency. In the group with pancreatic cancer, the three tests showed similar results, and the majority of the patients had normal values. In the patients with nonpancreatic diseases, abnormally high levels were found in five, by immunoassay, in four by electrophoresis, and in three by the wheat germ inhibition method. In the five cases with macroamylasemia, both inhibition assays erroneously demonstrated an abnormal P-isoamylase elevation. The results show that the three tests are equally useful for the diagnosis of acute pancreatitis, or chronic pancreatitis during an acute relapse. In these diseases, the immunoinhibition test would be the preferred assay because it is simple and rapidly performed.

Fasting serum gastrin and gastrin response to a protein meal were measured in a group of patients with chronic pancreatitis and in controls. No significant differences were found between the two groups of subjects. In patients with chronic pancreatitis no relation was found between gastrin release and the severity of pancreatic exocrine insufficiency.

Serum levels of amylase, pancreatic isoamylase, lipase, trypsinogen, and elastase 1 were determined in 41 patients with pancreatic carcinoma and compared with those 71 patients with chronic pancreatitis and 17 patients with digestive non-pancreatic carcinoma, in an attempt to evaluate their relative values in the diagnosis of pancreatic cancer. Trypsinogen and elastase 1 levels were the most frequently abnormal (56%), followed by pancreatic isoamylase (39%), lipase (34%), and amylase (27%). In 4 patients with resectable cancer levels of all serum enzymes were within normal limits, with the single exception of a low trypsinogen level in one patient. No significant differences in the behavior of serum enzymes were found between patients with pancreatic cancer and those with chronic pancreatitis or digestive non-pancreatic cancer. The results of our study indicate that measurement of serum pancreatic enzymes is of limited usefulness in the diagnosis of pancreatic cancer.

The secretion of bicarbonate, lipase, and chymotrypsin into the duodenum in response to exogenous stimulation with secretin, 1 CU/kg-h, plus caerulein, 100 ng/kg-h, was investigated in 12 patients, on an average, 20.7 months after total gastrectomy and in 14 control subjects. The secretion of bicarbonate and lipase was significantly lower in patients than in controls. The reduction in outputs compared with the control values was 47.9%, 38.7%, and 24.2% respectively for bicarbonate, lipase, and chymotrypsin. Eight of the 12 patients (67%) had steatorrhoea. No significant correlation was found between this parameter and lipase output. It is concluded that the exocrine pancreatic function is impaired in the majority of patients subjected to total gastrectomy. The impairment, which particularly affects bicarbonate and lipase, is generally mild to moderate.

Pancreolauryl test (PLT), a tubeless pancreatic function test, was performed in 40 consecutive patients suffering from chronic pancreatitis, in 21 patients with miscellaneous digestive diseases, and in 18 control subjects to assess its diagnostic sensitivity and specificity. N-benzoyl-L-tyrosyl-p-aminobenzoic acid test (PABA test) and secretin-cerulein test were also carried out to compare the diagnostic value of PLT with that of these two pancreatic function tests. PLT was abnormal in 22 of 40 patients with chronic pancreatitis (55%). In particular, pathological results were found in all patients with severe pancreatic insufficiency and only in four of 14 patients with mild to moderate insufficiency. PABA test showed a slightly lower sensitivity in severe insufficiency, and the same sensitivity in mild-moderate insufficiency. PLT was normal in all control subjects and in 17 of 21 patients with nonpancreatic digestive diseases. Its specificity (90%) was slightly higher than that of PABA test (82%). The results indicate that PLT may be used to support a diagnosis of severe pancreatic exocrine insufficiency, while in mild or moderate insufficiency its diagnostic value is limited.

We have measured serum immunoreactive pancreatic elastase 1 concentrations in 90 patients with pancreatic cancer in order to determine its usefulness in the diagnosis of this tumor. Abnormal elastase 1 concentrations were found in only 58 (64.4%) of the 90 patients. Fifty (55.5%) had abnormally high values, and eight (8.9%) had abnormally low values. No significant differences in elastase 1 levels were observed between patients with resectable cancer (n = 15) and those with unresectable cancer (n = 75). Moreover, no significant differences were found between elastase 1 concentrations of patients with pancreatic cancer and those of 71 patients with chronic pancreatitis. We conclude that serum elastase 1 measurement does not represent a significant advance in the diagnosis, whether early or late, of pancreatic cancer.

Phosphorylcholine and homocysteine have an important choleretic action and also potentiate exocrine pancreatic secretion by way of stimulation and a more effective preparation of the substrate against attack by lipolytic enzymes. The protection offered by pancreatic enzymes in the correction of the digestive insufficiency in the endoluminal stage is also known. An analysis was therefore made of the action of an association of phosphorylcholine homocysteine and digestive enzymes in cases of exocrine pancreatic insufficiency and primary or secondary malabsorption. This action was evaluated on the basis of the reduction of elimination of steatorrhoea. For this purpose, faecal lipids were determined with the method proposed by van de Kramer et al. The most significant results were obtained in cases where digestive insufficiency was most marked, where correction of the pancreatic enzyme deficiency and improved biliary function were particularly required.

Serum trypsin levels and exocrine pancreatic function were determined in twenty patients with chronic pancreatitis. Very low values of serum trypsin were found in patients with severe pancreatic insufficiency. In patients with mild or moderate pancreatic insufficiency serum trypsin levels were in the normal range.