[A case of Marfan's syndrome that required emergency Bentall's operation due to acute dissecting aortic aneurysm (DeBakey type II) following surgery of abdominal aortic aneurysm]

Graft replacement was performed in a 29-year-old man for an abdominal aortic aneurysm associated with Marfan's syndrome. Since the dissecting aortic aneurysm (DeBakey type II) accompanied by disruption of the right coronary artery developed 74 days after operation, the emergency Bentall's operation was successfully carried out with bypassing of the right coronary artery using a saphenous vein graft. Fifteen Japanese cases operated on for abdominal aortic aneurysm associated with Marfan's syndrome are reviewed, and the problems concerning surgery of abdominal aortic aneurysm and Bentall's operation are discussed.

[Invasive thymoma involving the liver: a case report of transdiaphragmatic extension]

A 38-year-old woman had an invasive thymoma which disseminated into the thoracic cavity and infiltrated the lateral liver surface. Such transdiaphragmatic extension by an invasive thymoma is rare, however, routine abdominal CT should be performed in invasive thymoma cases to avoid underestimating the extent of disease.

[Surgical management of desmoid tumors of the chest wall: a case report and review of literature]

A 45-year-old man without special predispositions showed a chest wall tumor with tenderness. A needle biopsy revealed a desmoid tumor which had invaded the muscles. A wide resection from the second to fifth rib was carried out and 4 years have passed without recurrence. A resection, at least 3 cm away from the lesion, is necessary for desmoid tumors which seem to have clear margins.

[Surgical management of multiple rib fractures: a case report of rib stapler]

A 66-year-old woman with multiple rib fractures was successfully treated with the use of Rib Staplers (Judet's struts made of titanium). Rib Staplers are effective for the stabilization of fractured ribs even if fracture lines are oblique.

[A case report of aortic wall reconstruction utilizing heparin-coated temporary bypass tube and roller pump system]

A 51-year-old man with stage IIIB (T4N2M0) adenocarcinoma of the lung underwent left pneumonectomy and aortic wall resection. In this operation a heparin-coated tube and roller pump system were used. Advantages of a heparin-coated tube and roller pump system for temporary bypass are as follows. 1) simple operative procedure. 2) controllable bypass flow. 3) no need for anticoagulants.

Modified segmental gastrectomy combined with vagotomy for a gastric ulcer near the gastro-esophageal junction

To avoid proximal gastrectomy which destroys the gastroesophageal closing mechanism, modified segmental gastrectomy with vagotomy was performed on 3 patients with gastric ulcers located in the stomach near the gastro-esophageal junction. These were all patients in whom a proximal gastrectomy would usually have been performed. The proximal line of resection did not encroach upon the mucosal rosette being within 1 cm of it following the margin of the ulcer. In each patient, the modified segmental resection of the upper stomach consisted of the surgical removal of a continuous strip of tissue including the ulcer and ulcer-bearing area along the wall followed by an end to end gastro-gastrostomy. In the 10 years following surgery, there have been no signs of reflux esophagitis, stricture, or recurrent ulcers in any of the 3 patients. This modified segmental gastrectomy with vagotomy is therefore recommended for gastric ulcers located near the gastro-esophageal junction.

[Surgical treatment of advanced (p-stage III.IV) lung cancer less than 2.0 cm in size]

We treated surgically 567 patients with primary lung cancer from June 1975 to December 1989. There were nine patients with advanced (p-stage III.IV) lung cancer less than 2.0 cm in size. The five year survival rate was 50.8%. The histological diagnosis was adenocarcinoma in 6, squamous cell carcinoma in 3. A curative resection was performed in seven of nine patients. Six patients had one level metastasis of mediastinal lymph node. Three patients in whom relative curative resection was performed at surgery later developed regional recurrence. However, distant metastasis was not evident in all but one of nine patients. In conclusion surgical resection is considered to be significant in patients with advanced (p-stage III.IV) lung cancer less than 2.0 cm in size.

Serum carnitine and nutritional status in children treated with continuous ambulatory peritoneal dialysis

The serum carnitine (total carnitine), total protein, amino acid, and triglyceride levels were determined in children on continuous ambulatory peritoneal dialysis (CAPD). Compared with levels in controls, serum carnitine levels were significantly decreased in patients on CAPD for more than 4 months, while those of patients on CAPD for 1-3 months were not decreased. Patients on CAPD for more than 4 months also showed lower serum total protein levels than in normal controls. The mean triglyceride levels in patients on CAPD for both 1-3 months and more than 4 months were higher than those in normal controls. Among the amino acids, the serum levels of tryptophan, isoleucine, leucine, tyrosine, valine, serine, and asparagine were significantly lower in patients treated with CAPD than in normal controls, whereas the levels of other amino acids were either increased or not changed. Isoleucine and leucine levels showed a strong correlation with serum carnitine. Our data suggest that malnutrition plays a role in the decrease of serum carnitine levels in patients receiving CAPD.

[Significance of fiberoptic bronchoscopy after pulmonary resection of lung cancer for early detection in second lung cancer]

By the end of 1988, seventy five cases after pulmonary resection for lung cancer and one case after pulmonary resection for basal cell hyperplasia were examined with fiberoptic bronchoscopy as postoperative follow up. Endobronchial tumor was detected in 14 cases. In seven cases, endobronchial tumor was located at site far from the surgical bronchial anastomosis. These tumors were suspected as second lung cancer as long as examined by fiberoptic bronchoscopy. Histological type of all of these was squamous cell carcinoma. Re-operations were performed in five cases and two of them were early lung cancer. In 6 cases (13.6%) among 44 cases examined with fiberoptic bronchoscopy after pulmonary resection for central type squamous cell carcinoma, second lung cancer was detected. In the case of central type squamous cell carcinoma, usually the tumor appears to be of same histological type and at same location. Among those cases those who smoke heavily should be separated as high risk group. If this group is followed with fiberoptic bronchoscopy or sputum cytological examination, it is more possible to detect second lung cancer at an early stage.

Immune abnormalities and clinical course in childhood IgA nephropathy

Immunoglobulin production by peripheral blood mononuclear cells (PBMC) and lymphocyte subpopulations were studied in 56 children with IgA nephropathy (IgAN) and 22 healthy controls. All the patients had persistent proteinuria at the time of diagnosis, and were divided into three clinical groups on the basis of urinary findings at the time of examination: 27 patients had proteinuria with or without microscopic hematuria (group A; active stage), 9 had microscopic hematuria only (group B; healing stage) and 20 had normal urine (group C; remission stage). PBMC from the patients in group A cultured without mitogenic stimulation produced significantly more IgA and IgG than those from controls (p less than 0.05). After polyclonal B cell stimulation with pokeweed mitogen (PWM), PBMC from patients in group A produced significantly more IgA than those from group B (p less than 0.05), group C (p less than 0.05) or controls (p less than 0.01), and produced significantly more IgG than those from group B (p less than 0.05) or controls (p less than 0.01). However, there was no significant difference in PWM-stimulated IgG production between groups A and C. PWM-stimulated PBMC from patients in group C produced significantly more IgA and IgG than those from controls (p less than 0.05). There were no significant differences in lymphocyte subpopulations among groups A, B and C and controls. These findings show that the clinical course of childhood IgAN is correlated with IgA production by PBMC suggesting that overproduction of IgA might be responsible for the pathogenesis of IgAN in children.

[Partial volume effect in MRI--a phantom study]

According to the direction and the thickness of the imaging slice in tomography, the border between the tissues becomes unclear (partial volume effect). In the present MRI experiment, we examined border area between fat and water components using phantom in order to investigate the partial volume effect in MRI. In spin echo sequences, the intensity of the border area showed a linear relationship with composition of fat and water. Whereas, in inversion recovery and field echo sequences, we found the parameters to produce an extremely low intensity area at the border region between fat and water. This low intensity area was explained by cancellation of NMR signals from fat and water due to the difference in the direction of magnetic vectors. Clinically, partial volume effect can cause of mis-evaluation of walls, small nodules, tumor capsules and the tumor invasion in the use of inversion recovery and field echo sequences.

[Pulmonary complication after resection of lung cancer--difficulty in expectoration and cough dynamics]

From January 1975 to December 1986, 415 patients were operated for primary lung cancer. Postoperative pulmonary complications were observed in 83 patients and among them 48 patients (57.8%) suffered from difficulty in expectoration. Postoperative expectoration mostly depends on the ability of coughing. To evaluate cough dynamics, expiratory flow-rate and volume at voluntary maximal cough were measured. The more expiratory flow rate and volume a cough has, the more effective it is for expectoration. In those patients with decreased FEV1.0, or respiratory muscle weakness because of emaciation and aging, or severe pain in the wound, the cough dynamics was decreased. By cleaning retained secretions in the respiratory tract, postoperative pulmonary complications would be prevented. However in cases where the decrease in postoperative cough dynamics is predictable, application of limited resection should be considered as well.

[Diagnostic value of the cortico-medullary contrast on dynamic CT and MRI in chronic renal parenchymal diseases]

Correlation between cortico-medullary contrast (CMC) and dynamic CT or MRI for chronic renal parenchymal diseases was evaluated compared with serum creatinine level (Cr). Forty two kidneys of 23 patients were chronic glomerulonephritis (12), chronic pyelonephritis (12), chronic renal failure (4), and other diseases (14). Thirty two kidneys with low Cr (under 1.6) were demonstrated the good CMC by dynamic CT and T1-weighted image (IR) of 0.5 T. Six with middle of Cr (between 1.6 and 3.0) were showed a decrease in CMC and four with high Cr (over 3.0) had no CMC. CMC correlated with Cr.

Focal and diffuse membranoproliferative glomerulonephritis in children

Characteristic deposition of C3 has been reported in type I membranoproliferative glomerulonephritis (MPGN). Immunofluorescence microscopy shows diffuse granular deposition of C3 along the majority of capillary loops with lobular pattern. To determine the specificity of this immunofluorescence finding which might aid in distinction between type 1 MPGN, particularly focal MPGN, and the other glomerulopathies, 530 renal biopsies from 437 children were studied retrospectively. Nineteen patients showed diffuse granular deposits of C3 along the capillary walls with lobular distribution. Three patients had lupus nephritis. Nine patients showed the light microscopic changes of diffuse type I MPGN with the characteristic double-walled capillaries. Six patients showed the changes of focal MPGN, and 1 had diffuse mesangial proliferation but without double contours, and they were regarded as examples of a mild or early form of MPGN. A similar deposition of C3 was not seen in the 418 patients with other conditions. We concluded that diffuse granular deposits of C3 along the capillary walls with a lobular distribution appear to be confined to type I MPGN and lupus nephritis and are seen in all patients with diffuse and focal type I MPGN.

Mesangial changes in IgA nephropathy in children

The mesangial changes in 92 renal biopsy specimens from 81 children with IgA nephropathy were correlated with the clinical and the other renal biopsy findings. Three types of mesangial changes were identified: mesangial hypercellularity was predominant compared with the increase in matrix in 34 biopsy specimens (type A), the degrees of mesangial hypercellularity and matrix increase were similar in 36 (type B) and matrix increase was predominant in 22 (type C). The interval between the onset of disease and biopsy was significantly shorter in biopsies with type A mesangial changes (P less than 0.01) and significantly longer in those with type C (P less than 0.01). Serial pathologic observations revealed that predominant mesangial hypercellularity was almost exclusively seen in the initial biopsy but predominant matrix increase was usually seen in the follow-up biopsy. The percentage of glomeruli showing sclerosis was significantly higher in biopsies with type C mesangial changes (P less than 0.05). At the latest follow-up, 58% of the patients showing type A and 57% showing type B lost their proteinuria, whereas only 9% showing type C lost their proteinuria (P less than 0.01). These findings suggest that predominant mesangial hypercellularity is characteristic of the early lesion of childhood IgA nephropathy, and progression of disease leads to gradual decrease of mesangial cellularity and increase of matrix with sclerosis.

Insulin response following intravenous glucose administration in dogs with obstructive jaundice

In order to further clarify the circulating insulin kinetics in obstructive jaundice, five anesthetized dogs were given a 15-min intravenous infusion of 1 g/kg glucose before and during the first 1 to 2 weeks after a common bile duct ligation. Significantly higher blood glucose levels, a lower insulin response in femoral vein blood, and a lower initial insulin response in portal vein blood were observed following glucose administration in the animals with jaundice. The ratio of (integrated portal insulin response-integrated femoral insulin response)/(integrated portal insulin response) was significantly increased in the animals with jaundice when compared with that of the control animals. These results suggest that a low peripheral insulin response following glucose administration in obstructive jaundice is induced by an augmented insulin extraction in the liver and/or peripheral tissue as well as by an insulin hyposecretion from the pancreas.

Henoch-Schoenlein nephritis and IgA nephropathy in children: a comparison of clinical course

The clinical presentation, initial laboratory and renal biopsy findings, and subsequent clinical course were studied and compared in 128 children with Henoch-Schoenlein (HS) nephritis and in 206 children with IgA nephropathy. The clinical and pathological findings of the two conditions were similar. After a mean follow-up period of 5 years, 72 patients (56%) with HS nephritis and 67 (32%) with IgA nephropathy showed no demonstrable abnormality, 29 (23%) with HS nephritis and 103 (50%) with IgA nephropathy had minor urinary abnormalities, 7 (5%) with HS nephritis and 26 (13%) with IgA nephropathy had heavy proteinuria and/or hypertension, and 20 (16%) with HS nephritis and 10 (5%) with IgA nephropathy had developed chronic renal failure. A worse outcome was significantly associated with the more severe clinical presentations and more severe glomerular changes by light microscopy in HS nephritis, whereas there was no relationship between the severity of clinical presentation and glomerular changes and prognosis in IgA nephropathy. These findings suggest that HS nephritis is an acute disease and prognosis is associated with the severity of glomerular changes at onset, while IgA nephropathy is a chronic, slowly progressive glomerular disease.

Clinical course of immunoglobulin A nephropathy in children

The clinical presentation, initial laboratory and renal biopsy findings, and subsequent clinical course of IgA nephropathy were studied retrospectively in 200 children, and findings in those with younger onset and older onset were compared. Eighty-three patients were 8 years of age or younger (group 1) and 117 were 9 years of age or older (group 2) at onset. There were no differences between the two groups with regard to sex, initial renal function, incidence of hypertension and macroscopic hematuria, degree of proteinuria, and pathologic findings. At the latest follow-up, two patients in group 1 and eight in group 2 had chronic renal failure, and five patients in group 1 and 21 in group 2 had heavy proteinuria with or without hypertension (P less than 0.01), whereas 36 (43%) patients in group 1 and 29 (25%) in group 2 had normal urine, blood pressure, and glomerular filtration rate (P less than 0.01); the disease followed a significantly more benign course in children with younger onset than in those with older onset. These observations suggest some age-related differences in the natural history of childhood IgA nephropathy.

Lysis of the glomerular basement membrane in children with IgA nephropathy and Henoch-Shönlein nephritis

An electron-microscopic study of the glomerular basement membrane was made on 242 renal biopsies from 222 children with a variety of renal diseases. Lysis of the basement membrane was observed in 16 of the 25 children with Henoch-Schönlein nephritis, 36 of the 72 with IgA nephropathy and one with acute poststreptococcal glomerulonephritis. Lysis was frequently associated with subepithelial dense deposits and polymorphonuclear leukocytes, and these are thought to play a role in the lytic process. There was a significant correlation between the presence of lysis of the basement membrane, the degree of proteinuria and the severity of glomerular changes by light microscopy. These findings suggest that the degree of lysis is an indication of the severity of the disease and lysis is associated with progressive disease and a worse prognosis in Henoch-Schönlein nephritis and IgA nephropathy.

Vascular changes associated with growth of primary and transplantable pancreatic adenocarcinomas induced in Syrian golden hamsters by N-nitrosobis(2-oxopropyl)amine (BOP) and N-nitrosobis(2-hydroxypropyl)amine (BHP)

Microangiographic and histological methods were used to characterize vascular structure of primary and transplantable pancreatic adenocarcinomas induced by propylnitrosamines in Syrian golden hamsters. Originally of well-differentiated tubular morphology, serial transplantation subcutaneously to the back region was not associated with change in histopathological pattern or increase in invasive or metastatic potential. In contrast, pancreatic subserosal grafts displayed prominent invasion of surrounding tissues. Whereas primary tumors induced by N-nitrosobis(2-oxopropyl)amine (BOP) and those transplanted subserosally were characterized by hypovascularity, subcutaneous transplantation resulted in hypervascular tumors. Encasement, which is defined as invasion of normal arteries by the tumor, showing uneven caliber, irregular outline, appeared on earlier microangiographic findings rather than luminal irregularity, which is change of tumor vessels in neovascularization and occurs in tumor blood vessels subsequent to transplantation. The vascular component of subcutaneously transplanted tumors had a total vessel length ranging from 9.2 +/- 0.7 mm to 18.1 +/- 1.1 mm, a total vessel surface from 2.5 +/- 0.4 mm2 to 9.3 +/- 0.6 mm2 and a total vessel volume from 0.07 +/- 0.02 mm3 to 0.49 +/- 0.04 mm3, indicating that the vessels were of relatively large diameter and short length.

Surgical management of acute hemorrhagic postbulbar duodenal ulcer after a previous major surgical procedure

The choice of operation for acute hemorrhagic postbulbar duodenal ulcer after an operation is discussed. Distal partial gastrectomy was performed in six patients. The ulcer was treated by resection, suture, or removal by mucoclasis. Hemostasis was attained in five patients. In another, multiple ulcers were observed in the descending portion of the duodenum and gastrectomy failed to control hemorrhage, resulting in death. Rebleeding was observed in two, one from a newly formed ulcer in the upper part of the papilla of Vater after gastrectomy with truncal vagotomy and which was halted by suture of the ulcer and another was from a newly formed ulcer in the remnant stomach after gastrectomy and which was halted by selective vagotomy and ligation of the left gastric artery. It is recommendable to perform a subtotal gastrectomy and vagotomy combined with removal of the ulcer by mucoclasis or ulcer suture. In some cases, pancreatoduodenectomy may have to be done.

Effect of truncal vagotomy on intestinal phase of pancreatic polypeptide release in dogs

In order to elucidate the role of the vagus nerve in the intestinal phase of pancreatic polypeptide (PP) release, mongrel dogs were given a 4-min intraduodenal infusion of saline, 20% glucose, or 10% soybean oil solution (50 ml each), before and one month after truncal vagotomy including pyloroplasty (TV). The saline infusion did not change the basal PP level, while the glucose infusion elicited a monophasic transient PP release, and the soybean oil infusion elicited a monophasic prolonged PP release in the intact dogs. The PP response following glucose infusion was almost abolished after TV, while the PP response to fat was attenuated, but a significant increase was nevertheless observed after TV. These results suggest that the vagus nerve has an important role in the intestinal phase of PP release and that other factors, e.g. hormonal, might also be involved in the regulatory mechanism, especially after fat loading.

Effect of truncal vagotomy on neurotensin-like immunoreactivity release in dogs

To elucidate the relationship between the vagus nerve and circulating neurotensin release, mongrel dogs were given an intraduodenal infusion of a 50 ml water solution containing 10 g glucose (n = 4) or 5 g soybean oil (n = 7) over a period of 4 min before and after truncal vagotomy with pyloroplasty. In the prevagotomized animals only a slight increase of neurotensin-like immunoreactivity (NTLI) was observed following glucose infusion, while NTLI in response to fat infusion was significantly increased. After vagotomy, NTLI release following fat infusion was significantly decreased when compared to untreated control animals, suggesting that vagotomy causes a major alteration in circulating NTLI release and that the vagus nerve may play a definite role in fat-induced NTLI release.

The failure of truncal vagotomy to affect motilin release in dogs

To elucidate the relationship between vagus nerve and motilin release, we have studied the influence of truncal vagotomy with pyloroplasty (TV) on motilin release in the fasting state and for 120 min following an intraduodenal administration of 10 g glucose in a 50-ml water solution or 5 g soybean oil. TV did not influence the intermittent fluctuation or concentration of plasma motilin in the fasting state. Intraduodenal glucose administration inhibited motilin release, but this was not affected by TV. Intraduodenal fat administration accelerated motilin release, but this effect also was not affected by TV. These results suggest that motilin secretion in the fasting state and after nutrient ingestion is not influenced by TV.

Effect of truncal vagotomy on GIP release induced by intraduodenal glucose or fat in dogs

In order to elucidate the role of the vagus nerve in the release of gastric inhibitory polypeptide (GIP), mongrel dogs were given a 4-min intraduodenal infusion of 10 g glucose or 5 g soybean oil before and again 1 month after truncal vagotomy (TV). The basal GIP concentrations were significantly elevated after TV. The plasma GIP levels following glucose infusion in the vagotomized dogs were significantly higher than those in the untreated dogs, whereas the GIP levels following fat infusion were not affected by TV. These results suggest that TV influences glucose-induced GIP release but not fat-induced GIP release, indicating that different mechanisms of the vagus nerve may be involved in glucose- and fat-induced GIP secretions.

Glomerular electron-dense deposits in childhood IgA nephropathy

An electron-microscopic study of the glomeruli was made on 154 children with IgA nephropathy and no evidence of systemic disease, in whom immunofluorescence microscopy had shown diffuse mesangial deposition of IgA. Mesangial deposits were observed in all but eight children. Subepithelial deposits were observed in 40 children and were almost always accompanied by both mesangial and subendothelial deposits. Subepithelial deposits were significantly associated with more severe clinical presentations, a worse outcome and more severe light microscopic glomerular changes. These observations support the concept that IgA nephropathy is an immune complex disease.

Usefulness of direct coronal CT in the diagnosis of urinary bladder tumor

Direct coronal CT was performed on 6 cases of urinary bladder tumor in which conventional axial transverse CT failed to depict the relationship between the lesion and bladder wall. GE CT/T 8800 was used, and the bladder was scanned with patients crouched on the table opposite the gantry. The relationship between the tumor and bladder wall as well as the surrounding organs was visualized in 5 of 6 cases examined. THe CT diagnosis and histological findings coincided in 4 of these 5. Direct coronal CT was useful for diagnostic determination of clinical stage for tumors occurring in the apical or basal region of the urinary bladder.

The evidence for the regulatory role of endogenous GIP as a glucose dependent insulinotropic hormone in patients with duodenal ulcer

In order to investigate the mechanism of GIP secretion and the role of endogenous GIP in the enteroinsular axis in duodenal ulcer patients, we have compared plasma GIP, insulin, and blood glucose responses to oral glucose ingestion in 10 duodenal ulcer patients, 5 patients with total gastrectomy, and 20 normal subjects. The mean basal level of plasma GIP in totally gastrectomized patients was significantly higher than in normal subjects, while in duodenal ulcer patients the value was not different from that of controls. Plasma GIP and insulin responses to oral glucose loading were significantly higher than normal in both groups. The degree of exaggerated plasma GIP and insulin secretions was more prominent and earlier in totally gastrectomized patients than in duodenal ulcer patients, and was positively correlated with the blood glucose increase during glucose ingestion. On the other hand, no significant change in GIP secretion during insulin-induced hypoglycaemia was observed in normal subjects, duodenal ulcer patients, or patients with selective proximal vagotomy. These findings indicate that the exaggerated GIP response to oral glucose in duodenal ulcer patients may be due not to increased vagal tone, but to more rapid incoming load. We found also that the hypersecretion of GIP induced by glucose ingestion in patients with duodenal ulcer and total gastrectomy may be responsible for the hyperfunction of the enteroinsular axis in these patients.

Coarse areae gastricae in the proximal body and fundus: a sign of gastric hypersecreton. Radiological and endoscopic correlation

The clinical significance of coarse areae gastricae in the proximal body and fundus on the double-contrast radiograph was investigated in 60 patients. Radiographic findings were correlated with endoscopic features and biochemical analysis of gastric juice as well as with the clinical and endoscopic features of 98 controls with a regular mucosal pattern. The patients with the coarse pattern had more gastric secretion than the control group. Ulcers were seen in 65% of patients, particularly in the duodenum (48%); they were more commonly associated with a coarse pattern and closely related to gastric hyperacidity. Coarse areae gastricae in the proximal body and fundus may be a useful radiographic sign in assessment of gastric secretion.

Availability of plasma pancreatic polypeptide measurement in diagnosis of chronic pancreatitis

Plasma pancreatic polypeptide (PP), a newly recognized pancreatic hormone, was studied in healthy subjects and patients with chronic pancreatitis. After an oral load of 50 g of meat extract, the plasma concentration of PP showed a rapid fourfold rise at 20 min in healthy controls. In contrast, the plasma PP level rose only 1.8-fold in patients with chronic pancreatitis. This difference was statistically significant (P less than 0.05). The increase rate of the PP level during the test in each subject correlated significantly (P less than 0.01) with total amylase output and maximal amylase concentration measured by the pancreozymin-secretin test. Thus, it is suggested that the measurement of the plasma PP level may be a useful tool to diagnose chronic pancreatitis.