The enzyme levels in blood are not affected by oral administration of a pancreatic enzyme preparation (Creon 10,000) in pancreas-insufficient pigs

After oral intake, small amounts of intact protein may be absorbed into the blood circulation. The current study investigated whether orally administered pancreatic enzymes were absorbed from the intestine. The study included 28 pigs; 3 control pigs with intact pancreatic function and 25 pigs that were made exocrine pancreas insufficient by duct ligation (20 pigs) or total pancreatectomy (5 pigs). The pigs received a pancreatic enzyme preparation (0, 2, 4, or 8 g of Creon 10,000) together with the feed. The blood plasma was analyzed for pancreatic lipase activity with a [3H]-triolein substrate assay, while (pro)colipase and cationic trypsin(ogen) levels were measured with enzyme-linked immunosorbent assay (ELISA). Administration of Creon (0-8 g) caused no significant changes in plasma (pro)colipase or cationic trypsin(ogen) levels. Lipase activity peaks in plasma samples were found, but they did not correspond to the administration of Creon. The potential source of these plasma lipase activity peaks is discussed. The results showed no absorption into blood of pancreatic enzymes after oral administration (0, 2, 4, or 8 g of Creon mixed with 100 g of feed) to pancreas-insufficient pigs.

Rescue of defective pancreatic secretion in cystic-fibrosis cells by suppression of a novel isoform of phospholipase C

BACKGROUND

Cystic fibrosis is caused by mutations in the gene encoding an ion-transport protein, the cystic-fibrosis transmembrane conductance regulator (CFTR). Defective secretion of anions is the primary cause of many of the clinical manifestations of cystic fibrosis, including pancreatic insufficiency. We aimed to identify a molecular mechanism from which a new method to circumvent defective pancreatic secretion could be derived.

METHODS

Multiple-human-tissue RT-PCR and semiquantitative RT-PCR analyses were used to examine gene expression. An antisense technique was used in conjunction with radioimmunoassay, Fura-2 spectrofluorometry, immunohistochemistry, and the short-circuit current technique (Ussing chamber) for elucidation of gene function and its application in rescuing defective pancreatic secretion.

FINDINGS

We cloned a newly identified gene, NYD-SP27, which has structural similarity to an isoform of phospholipase C. NYD-SP27 was expressed endogenously in human pancreatic-duct cells and upregulated in cystic fibrosis. Suppression of NYD-SP27, by transfection of its antisense into human cystic-fibrosis pancreatic-duct cells, resulted in augmentation of phospholipase-C-coupled calcium-ion release and protein kinase C activity, improvement in the amount of mutated CFTR reaching the plasma membrane, and restoration of cAMP-activated pancreatic anion secretion.

INTERPRETATION

NYD-SP27 exerts an inhibitory effect on phospholipase-C-coupled processes that depend on calcium ions and protein kinase C, including CFTR trafficking and function. Its upregulation in pancreatic-duct cells may reveal a previously unsuspected defect in cystic fibrosis contributing to pancreatic insufficiency, and thus represents a new target for pharmacological intervention in cystic fibrosis.

[Clinical surveillance of patients with chronic recurrent pancreatitis]

Clinical surveillance of patients affected by chronic relapsing pancreatitis is not a particularly difficult task. In fact, a number of precise landmarks is available such as recurrence of pain and nutritional conditions, possibly enriched by biochemical (specially serum pancreatic enzymes) and imaging data (US, CT, MR), which also may be periodically scheduled. Despite the opinion of some experts, the best timing for the periodical checks should probably be decided on an individual basis. A suitable surveillance program may also be useful to favour the patient compliance and to implement any therapeutic measures.

Comparison of steatocrit and fat absorption in persons with cystic fibrosis

BACKGROUND

Exocrine pancreatic insufficiency is a common problem in persons with cystic fibrosis causing malabsorption and poor growth. The 72-hour fecal fat study is the best qualitative measure of fat malabsorption used in clinical practice. This test has several drawbacks, which include cost and logistics. The steatocrit has been proposed as a rapid method to assess fat malabsorption.

OBJECTIVES

The objective of this study was to determine whether the steatocrit is an accurate estimation of fat malabsorption in persons with cystic fibrosis.

METHODS

Forty-nine stool samples for steatocrit processing were obtained from 72-hour fecal fat collections performed on twenty-seven persons with cystic fibrosis. Stools were weighed and homogenized with sand and water. The emulsified specimen was pipetted into heparinized capillary tubes and centrifuged for 15 minutes. The length of the fatty layer was compared to the length of the solid layer plus the fatty layer in each tube to determine the steatocrit value. Four steatocrit mixtures were evaluated: (1) standard steatocrit, (2) dilute steatocrit, (3) acid steatocrit, (4) dilute acid steatocrit. Steatocrit values were compared with the coefficient of fat absorption determined from the 72-hour fecal fat collection.

RESULTS

The correlation coefficient of the steatocrit and the coefficient of fat absorption ranged from -.045 to -.491. Only the coefficient of fat absorption and the acid steatocrit had a significant correlation ( = 0.033).

CONCLUSION

The steatocrit is an imprecise measure of fat absorption and not clinically useful in estimating steatorrhea.

[Markers of oxidative damage in blood of children with cystic fibrosis]

In cystic fibrosis (CF), as a result of chronic pulmonary infections and digestive malabsorption, an imbalance between the production of reactive oxygen species and their inactivation by protective systems is observed. This may cause impairment of cell metabolism and oxidative injury. The aim of this study was to examine whether markers of oxidative damage to protein (protein carbonyls) and lipids (malondialdehyde) may be modified in cystic fibrosis patients with pancreatic insufficiency. We have found that mean concentration of plasma protein carbonyls was 0.835 nmol/mg protein (the range of 0.31-1.71 nmol/mg protein) in CF patients (n = 57) and was higher by 30% than that in controls (n = 20). Plasma concentration of malondialdehyde (MDA) was 2.98 mumol/l in the range of 1.23-4.77 mumol/l. Among fifty seven patients studied, in 30 children MDA level was elevated above the highest values observed in the healthy group (2.80 mumol/l). Total radical-trapping antioxidant parameters (TRAP) amounted to 629 mumol/l and 735 mumol/l in CF patients and control, respectively. The difference was statistically significant (p < 0.005). The obtained results indicated that in CF patients oxidative stress caused oxidative modification of proteins and peroxidation of lipids which was accompanied by lowering of antioxidant protection. These results indicate that certain CF patients (especially those with exocrine pancreatic insufficiency) are susceptible to oxidative damage, therefore it seems that an adequate and balanced diet is essential for achieving and maintaining normal antioxidant defenses.

Fecal elastase-1 as a test for pancreatic function: a review

Pancreatic elastase-1 is a specific human protease synthetized by the acinar cells. Immunoreactive elastase-1 cannot be detected in either porcine or bovine pancreatic enzyme preparations. It is very stable and, in contrast to fecal chymotrypsin, elastase is unaffected by exogenous pancreatic enzyme treatment, and correlates well with exocrine pancreatic function tests. The measurement of this proteolytic enzyme in stool by means of an enzyme-linked immunosorbent assay (ELISA) is a sensitive, specific, and relatively inexpensive non-invasive test. It is an accurate function test for patients with chronic pancreatitis confirmed by endoscopic retrograde cholangiopancreatography and computerized axial tomography. It shows higher sensitivity and specificity for exocrine pancreatic insufficiency than fecal chymotrypsin determination and is comparable to oral pancreatic function tests such as the pancreolauryl test.

p53 protein overexpression in bone marrow biopsies of patients with Shwachman-Diamond syndrome has a prevalence similar to that of patients with refractory anemia

CONTEXT

Shwachman-Diamond syndrome (SDS) is a rare inherited disorder characterized by pancreatic insufficiency, neutropenia, and in some patients, metaphyseal dysostosis. Patients with SDS are at a high risk for development of bone marrow failure, myelodysplastic syndrome, and acute leukemia. The p53 gene plays a major role in cell-cycle regulation, particularly in the presence of a genetic alteration in DNA, a critical step for the initiation of leukemogenesis. p53 gene up-regulation and p53 protein overexpression may occur as a cellular reaction to significant DNA damage. Shwachman-Diamond syndrome and refractory anemia patients have close similarities in the prevalence of acute leukemia and in cell-cycle changes in bone marrow cells. This similarity was further investigated for p53 protein overexpression using archived tissue from patients with hematologic diseases having various leukemic propensities, including SDS and refractory anemia.

METHODS

Immunohistochemical staining for p53 protein overexpression was performed on bone marrow biopsies from 9 patients with SDS. These specimens were compared with biopsies from 71 patients with acquired hematologic disorders with variable risk levels for leukemia, including acquired aplastic anemia (n = 14), refractory anemia (n = 46), and various acquired cytopenias (n = 11), as well as 37 control subjects.

RESULTS

p53 protein overexpression was identified only in patients with SDS and in patients with refractory anemia; these groups exhibited comparable prevalences of 78% and 72%, respectively. None of the patients with acquired aplastic anemia, acquired cytopenias, or in the control group showed overexpression of p53 protein.

CONCLUSION

The prevalence of p53 protein overexpression in SDS is significantly different from that in acquired aplastic anemia and acquired cytopenias, but it is similar to the prevalence in refractory anemia. We speculate that p53 protein overexpression in this bone marrow failure syndrome may represent an early indicator of significant DNA genetic alteration, which is a crucial step in the process of leukemogenesis.

Expression of CD5 on hematogones in a 7-year-old girl with Shwachman-Diamond syndrome

We report increased numbers of hematogones in a 7-year-old girl with pancytopenia due to Shwachman-Diamond syndrome. Her hematogones expressed the T-cell marker CD5 as well as CD19, CD10, and CD20, and terminal deoxynucleotidyl transferase and HLA-DR. These findings suggest that hematogones are precursors of both CD5-positive B cells and CD5-negative B cells. Thus CD5-positive B cells in bone marrow may be derived from bone marrow stem cells, and not from the residual fetal B cells of yolk sac/liver origin. The finding of CD5 expression on hematogones also raises the possibility that neoplastic B cells of chronic lymphocytic leukemia, which characteristically co-express CD5 and CD19, may be derived from CD5-positive B-cell precursors in bone marrow and not from mature B cells in lymph nodes.

Iron, zinc, and copper concentration in serum, various organs, and hair of dogs with experimentally induced exocrine pancreatic insufficiency

The concentration of iron, zinc, and copper in serum, pancreas, liver, duodenum, kidneys, myocardium, brain, and hair was studied in dogs with experimentally induced exocrine pancreatic insufficiency. Exocrine pancreatic insufficiency was performed surgically in eight healthy, 8-month-old, mongrel dogs (group I). An equal number of dogs, of the same breed and age, were used as controls (group II). One month postoperatively, the dogs in group I showed symptoms of exocrine pancreatic insufficiency, confirmed by the serum Trypsin-like immunoreactivity test, and on autopsy, by histological examination of the pancreas. At the end of the experiment (20-week duration) the dogs in both groups were sacrificed. The values of serum iron, percentage transferrin saturation, and iron concentration in pancreas, duodenum, and kidneys in group I dogs were significantly higher than those in control animals. The concentrations of zinc in serum, pancreas, and myocardium and of copper in serum, pancreas, duodenum, myocardium, and hair in group I dogs were significant lower than those in control animals. Histological examination of various organs of group I dogs revealed severe atrophy and fibrosis of the pancreas, fatty infiltration of the liver, destruction and reduction in height of the villi of the duodenal epithelium, and diffuse infiltration of the duodenal lamina propria with lymphocytes and plasmocytes.

Involvement of cellular calcium in exocrine pancreatic insufficiency during streptozotocin-induced diabetes mellitus

This study investigates the effects of the islet hormones insulin (Ins), glucagon (Glu), and somatostatin (Som) with nerve stimulation (EFS) acetylcholine (ACh) and cholecytokinin-octapeptide (CCK-8) on amylase secretion and intracellular free calcium concentration [Ca(2+)](i) in the pancreas of age-matched control and diabetic rats. Either Ins, Glu or Som elicited small increases in amylase secretion from the pancreas of age-matched control animals compared to a much larger increase in amylase secretion with either EFS, ACh or CCK-8. Combining the islet hormones with either EFS, ACh or CCK-8 resulted in marked potentiation of amylase output. In the diabetic pancreas, the islet hormones had no effect on amylase secretion compared to diabetic control. Moreover, either EFS, ACh or CCK-8 evoked a much smaller increase in amylase output compared to age-matched control. In addition, the islet hormones failed to potentiate the secretory effects of either EFS, ACh or CCK-8. In fura-2 loaded acinar cells from age-matched control pancreas either Ins or Glu elicited a small increase in [Ca(2+)](i) whereas Som had no effect. Both ACh and CCK-8 evoked large increases in [Ca(2+)](i) compared to control. Combining either Ins, Glu or Som with either ACh or CCK-8 resulted in a marked elevation in [Ca(2+)](i) compared to the responses obtained with either the islet hormones, ACh or CCK-8 alone. In diabetic fura-2 loaded pancreatic acinar cells, the islet hormones had no effect on [Ca(2+)](i) compared to control and moreover, the responses were much smaller than those obtained in acinar cells from age-matched control. Both ACh and CCK-8 induced large increases in [Ca(2+)]( i) in diabetic acinar cells. However, combining the islet hormones with either ACh or CCK-8 failed to enhance [Ca(2+)](i) compared to the reponses obtained in acinar cells from age-matched control. The results suggests that [Ca(2+)](i) homeostasis is deranged during diabetes mellitus and this in turn is probably associated with reduced pancreatic amylase secretion.

Detection and follow up of exocrine pancreatic insufficiency in cystic fibrosis: a review

Pancreatic function testing is particularly difficult when the degree of remaining function has to be quantified. Detection of pancreatic insufficiency can suggest the diagnosis of cystic fibrosis (CF). It is, however, also important to follow the degree of pancreatic insufficiency in CF since its function can decline with age. Adaptation of pancreatic enzyme replacement therapy on residual function is necessary. Different tests with their advantages and disadvantages are critically reviewed in this article with respect to specificity, sensitivity, performance and cost-effectiveness.

CONCLUSION

Elastase-1 detection in faeces is probably the easiest test for the detection of pancreatic insufficiency in cystic fibrosis. For clinical follow-up tests, measuring the fat assimilation such as steatocrit and breath tests are more suited.

Bone mineral metabolism, bone mineral density, and body composition in patients with chronic pancreatitis and pancreatic exocrine insufficiency

BACKGROUND

Calcium and vitamin D homeostasis seem to be abnormal in patients with exocrine pancreatic dysfunction resulting from cystic fibrosis. Only a few studies have evaluated and described bone mineral metabolism in patients with chronic pancreatitis and pancreatic insufficiency.

METHODS

Thirty-two patients with chronic pancreatitis and residual exocrine pancreatic function (group 1) and 26 patients with pancreatic exocrine insufficiency (i.e., meal-stimulated intraduodenal lipase <10% of lowest normal range and steatorrhea) (group 2) were studied. Serum levels of total calcium, phosphate, 25 (OH)D, 1.25(OH)2D, alkaline phosphatase, and parathyroid hormone were measured. Bone mineral density (BMD), bone mineral content (BMC), lean body mass (LBM), and fat mass (FM) were measured using a dual-energy X-ray absorptiometry (DXA) scanner.

RESULTS

Alcohol was a causative factor in 79% of the patients. Fifty-six percent in group 1 and 69% in group 2 had Z-scores of the BMD < -1. The mean Z-score was -1.16 +/- 1.29 in group 1 and -1.32 +/- 0.90 in group 2. The mean Z-score of the BMC was -1.02 +/- 1.17 vs -1.39 +/- 0.987. In both groups mean 25 (OH)D and mean 1.25(OH)2D were below reference range. Plasma concentrations of albumin-corrected calcium, alkaline phosphatase, and parathyroid hormone were in the upper range of the reference range. Mean Z-scores of LBM were -0.69 +/- 1.34 in group 1 vs -1.01 +/- 1.12 in group 2 and Z-scores of FM were -0.27 +/- 1.70 in group 1 vs -0.95 +/- 1.01 in group 2 (p <0.05).

CONCLUSION

Patients with chronic pancreatitis, in particular patients with advanced disease and steatorrhea, are at risk of developing significant bone loss. Despite normal body mass index the patients are characterized by loss of lean body mass and fat mass. The present study shows that these patients have decreased serum levels of vitamin D metabolites and low bone mass.

[Diagnostic value of fecal elastase test in pancreatic exocrine deficiency]

The diagnostic value of the estimation of faecal elastase-1, the new noninvasive direct pancreatic function test was evaluated in a total of 35 patients. Twenty one patients were diagnosed with chronic pancreatitis and categorized according to grades of exocrine pancreatic insufficiency based on the Lundh test, 14 patients in the control group had gastrointestinal disorders. Faecal elastase 1 was measured by ELISA method. The sensitivity, specificity, positive and negative predictive value and diagnostic accuracy of elastase determination was 71.4%, 92.8%, 88.2%, 81.2% and 83.7%, respectively in chronic pancreatitis. In the severe exocrine pancreas insufficiency group (n = 14), the sensitivity was 85.7%, while in the group with mild insufficiency (n = 7) the sensitivity was only 42.8%. The determination of faecal elastase is useful in the diagnosis of severe exocrine pancreas insufficiency, but it is not sensitive enough in the mild form of the disease.

A double-blind, randomized, multicentre, crossover study to prove equivalence of pancreatin minimicrospheres versus microspheres in exocrine pancreatic insufficiency

BACKGROUND

Modern pancreatin preparations consist of enteric-coated microspheres to protect the enzymes from gastric acid. There are, however, no clinical trials comparing different sizes of pancreatin microspheres with regard to fat excretion and fat intake.

AIM

To prove both equivalent efficacy and safety of conventional pancreatin microspheres and smaller pancreatin minimicrospheres in patients with exocrine insufficiency due to chronic pancreatitis.

METHODS

In this prospective, randomized, double-blind, multicentre, crossover trial, patients with a stool fat excretion of > 7.5 g/day during a placebo period were randomly assigned either to the minimicrosphere/microsphere treatment sequence or vice versa. The primary end-point was the coefficient of fat absorption, which was calculated from fat excretion and fat intake during the course of a standardized diet. Stool weight, clinical symptoms and the safety of the preparations were also evaluated.

RESULTS

Thirty-seven patients entered the study, of whom 23 fulfilled the criteria for the crossover period. In the per protocol analysis (n=18), the 90% confidence intervals for the coefficient of fat absorption of both crossover periods lay entirely within the equivalence range (P=0.02). The intention-to-treat analysis revealed similar results, but the equivalence range was slightly missed (P=0.07). Similar results were obtained for the secondary parameters and the reported adverse events.

CONCLUSIONS

Pancreatin minimicrospheres have been shown to be equally effective as microspheres in improving the coefficient of fat absorption in patients with exocrine insufficiency due to chronic pancreatitis.

Post-prandial intragastric and duodenal acidity are increased in patients with chronic pancreatitis

OBJECTIVES

Patients with chronic pancreatitis and exocrine insufficiency have lower intraduodenal pH compared to controls. It has been assumed that abnormal low intraduodenal pH in these patients not only results from impaired pancreatic bicarbonate secretion but also from an increased gastric acid load to the duodenum.

METHODS

We have tested this hypothesis by combined intragastric and intraduodenal 24 h pH monitoring in nine chronic pancreatitis patients with exocrine pancreatic insufficiency and nine healthy control subjects during standardized test conditions. Postprandial gastrin and cholecystokinin release were also determined.

RESULTS

Median 24-h intraduodenal pH (5.90 vs. 6.00) and intragastric pH (1.60 vs. 1.70) were not significantly different between patients and controls. However, in the 2-h postprandial periods intraduodenal pH was below five for a significantly higher percentage of time in chronic pancreatitis patients compared to controls (lunch: 14.5% vs. 0.17%, P=0.011; dinner: 24.1% vs. 5.75%, P=0.05). The post-dinner intragastric pH was below three for a significantly higher percentage of time in chronic pancreatitis patients vs. controls (72.2 vs. 48.9%, P=0.04). Postprandial gastrin release was not significantly different between the two groups. Postprandial secretion of cholecystokinin (CCK), as enterogastrone, was significantly (P < 0.01) reduced in chronic pancreatitis patients (78 +/- 13 pmol/L, 120 min) compared to controls (155 +/- 14 pmol/L, 120 min).

CONCLUSIONS

Median intraduodenal and intragastric pH are not significantly decreased in patients with chronic pancreatitis and exocrine insufficiency but the postprandial time with an acidic pH in the duodenum (pH < 5) and in the stomach (pH < 3) is significantly (P </= 0.05) increased.

Zinc metabolism in patients with exocrine pancreatic insufficiency

OBJECTIVE

Metabolism of zinc was studied by administering radioactive zinc (Zn65), and by performing metabolic balance studies in eight patients with exocrine pancreatic insufficiency and eighteen control subjects.

METHODS

Retention of radioactive zinc was measured by total body counter, and its urinary and fecal excretion by gamma scintillation counter. Metabolic balance studies were carried out by measuring dietary zinc intake as well as fecal and urinary excretion of zinc by atomic absorption spectrophotometry in this group of patients.

RESULTS

These studies revealed a 50% reduction in intestinal absorption of Zn65 in patients with exocrine pancreatic insufficiency as compared to alcoholic and non-alcoholic control subjects. In addition, there was a 2 to 4 fold increase (p<0.05) in urinary excretion of zinc in subjects with pancreatic disease. In pancreatic insufficiency, reduced zinc absorption and increased urinary zinc excretion were balanced by lower (p<0.05) endogenous excretion of zinc as evidenced by reduced excretion of Zn65 in feces during the second 4-day period. The mean biological half-life of Zn65 tended to be lower in patients with pancreatic insufficiency as compared to alcoholic control subjects, however the difference did not reach statistical significance.

CONCLUSION

These observations indicate marked alterations in zinc metabolism in patients with advanced chronic pancreatic disease and provide greater insight into development of zinc deficiency in this group of patients.

"Mixed" triglyceride breath test: methodological problems and clinical applications

Laboratory assessment of pancreatic function is unpleasant for the patient and time-consuming for the investigator since it requires duodenal intubation and measurement of maximal pancreatic enzyme output by means of perfusion techniques. Non-invasive indirect tests such as bentiromide test, pancreolauryl test and faecal fat measurement have been introduced in clinical practice but their results depend on the collaboration of the patient in collecting urine or stool. Moreover, faecal fat reflects fat malabsorption but it is neither sensitive nor specific to evaluate exocrine pancreatic function. With the aim to determine whether steatorrhea is due to pancreatic insufficiency, several 14C- (or 13C) breath tests have been developed in which triolein, trioctanoin, tripalmitin, and cholesteryl-octanoate are used as marker substances. In 1989, G. Vantrappen and its group in Leuven developed a breath test in which a new substrate was used: the [1,3-distearyl, 2[carboxyl-13C]octanoyl glycerol] or 13C-"mixed"-triglyceride (MT). The "mixed triglyceride breath test" (MTBT) was shown to be an excellent test of exocrine pancreatic insufficiency when compared with the maximal lipase output after CCK-pancreozymin stimulation. Aim of this paper is to review the methodology of the MTBT and its actual and future applications in clinical practice.

Comparative clinical evaluation of the 13C-mixed triglyceride breath test as an indirect pancreatic function test

BACKGROUND

Breath tests using stable isotopes of carbon or hydrogen are increasingly becoming established for the evaluation of various gastrointestinal functions, including measurement of exocrine pancreatic insufficiency. We wanted to evaluate the clinical relevance of the non-invasive, non-radioactive 13C-mixed triglyceride breath test in comparison with the secretin-caerulein test as the 'gold standard' of pancreatic function testing and with faecal chymotrypsin and elastase 1 in patients with mild and severe exocrine pancreatic insufficiency.

METHODS

The secretin-caerulein test, faecal fat analysis, 13C-mixed triglyceride breath test, faecal elastase 1, and chymotrypsin and various morphologic investigations were done in 26 patients with mild (n = 13) or severe (n = 13) exocrine pancreatic insufficiency and 25 patients with gastrointestinal diseases of non-pancreatic origin. Twenty-seven healthy volunteers served as normal controls. After a 12-h fast 200 mg mixed triglyceride (1,3-distearyl,2(carboxyl-13C)octanoyl glycerol) were orally administered with a test meal, and breath samples were taken before and at 30-min intervals for 5 h thereafter, and the increase in 13C/12C isotopic ratio in breath was analysed by mass spectrometry. Various modifications of the test procedure were investigated.

RESULTS

Specificity for impaired pancreatic function was higher for faecal elastase (90%) and equal for faecal chymotrypsin (82%) as compared with the various variables of the 13C-mixed triglyceride breath test (69-85%). The sensitivity of the 13C-mixed triglyceride breath test for total and separately for mild and severe exocrine pancreatic insufficiency was higher (total, 69-81%) than that of faecal chymotrypsin (total, 56%) but lower than faecal elastase (total, 92%).

CONCLUSION

The 13C-mixed triglyceride breath test very sensitively reflects severe exocrine pancreatic insufficiency (steatorrhoea) but has limited sensitivity for the detection of mild cases. With regard to the higher sensitivity and specificity, the higher practicability, and the much lower cost, determination of faecal elastase 1 concentrations is superior to the 13C-mixed triglyceride breath test and therefore remains the most reliable indirect pancreatic function test available today.

Effects of high-lipase pancreatin on fecal fat, neutral sterol, bile acid, and short-chain fatty acid excretion in patients with pancreatic insufficiency resulting from chronic pancreatitis

CONCLUSIONS

Steatorrhea was almost completely stopped and malabsorption of neutral sterols and short-chain fatty acids was reduced by treatment of high-lipase pancreatin in Japanese patients with pancreatic insufficiency whose dietary fat consumption is low.

METHODS

Fifteen patients with chronic pancreatitis complicated by steatorrhea who consumed an average of 48 g of dietary fats a day were selected as subjects and given 3 g of high-lipase pancreatin (lipase, 379,800 USP U/g), at each meal (total daily dose is 9 g) for a mean duration of 28.5 d. Fecal output and fecal fat neutral sterol, bile acid, and short-chain fatty acid excretion were determined before and after the course of pancreatin therapy.

RESULTS

Pancreatin administration resulted in significant reductions (P < 0.01) in fecal output (from 243.2 to 149.1 g), excretion of fecal fat, (from 12.3 to 3.9 g), animal sterols (from 816.3 to 604.6 mg), and short-chain fatty acids (from 52.6 to 18.5 mM). In contrast, no marked changes were recorded in fecal excretion of beta-sitosterol (a plant sterol), bile acids, or the hydroxy fatty acid fraction. Fecal fat and short-chain fatty-acid excretion showed strong correlations with fecal output.

Serum and fecal pancreatic enzymes in beta-thalassemia major

CONCLUSION

This study, using indirect tests, demonstrated that exocrine pancreatic function is impaired in a proportion of patients with beta-thalassemia major (TM), though this impairment is generally mild or moderate.

BACKGROUND

Impaired structure and function of the exocrine pancreas has been reported in patients with Beta-thalassemia major.

METHODS

In this study we measured fecal fats and serum and fecal pancreatic enzymes in 30 patients (13 M, 17 F) with TM, mean age 22.1 yr (range 14-39) and compared them with those of a matched group of healthy controls. Results were correlated with age, serum ferritin, blood transfusion, and various nutritional parameters. Enzymes assays included: serum pancreatic amylase (PA), lipase (L), trypsin (T), fecal chymotrypsin (FCT), and fecal elastase (FE).

RESULTS

No patient was positive for steatorrhea. Comparison of the mean values showed a significant difference only for FE (p < 0.002). Using only the fecal tests as a reference, we found that 12 patients had FE values below the cutoff limit; of these, five had values between 100 and 185 micrograms/g, three between 50 and 99 micrograms/g and four below 50 micrograms/g. Ten patients had FCT values below the cutoff limit; seven presented impairment in both tests and six of them had FE values below 100 micrograms/g (including four diabetics). No correlations were found between enzyme values and mean serum ferritin values or mean blood consumption over the previous 3 yr. No correlation was found between FE and FCT levels or between enzymes and age.

Postprandial glucose-dependent insulinotropic polypeptide and insulin responses in patients with chronic pancreatitis with and without secondary diabetes

OBJECTIVE

To study GIP and insulin release after a test meal in patients with chronic pancreatitis with and without secondary diabetes mellitus.

METHODS

28 patients with chronic pancreatitis were classified in groups I and II according to the presence or absence of secondary diabetes mellitus. Twelve healthy subjects were included as controls. After a test meal plasma GIP levels and serum insulin levels were determined at 0, 30, 60, 120 and 180 min.

RESULTS

A significant diminished GIP response was found in the groups of patients with respect to the control group. No association could be detected with severity of pancreatic insufficiency. Higher values of GIP were demonstrated at 60 and 120 min in patients without diabetes than in patients with it.

CONCLUSIONS

An abnormal GIP response is present in cases of chronic pancreatitis irrespective of the presence or severity of pancreatic insufficiency. This response is further affected if secondary diabetes mellitus is present.

Exocrine pancreatic insufficiency: accuracy and clinical value of the uniformly labelled 13C-Hiolein breath test

BACKGROUND AND AIMS

The 13C-Hiolein breath test (98% [U-13C] labelled long chain triglyceride mixture (highly labelled triolein) was evaluated as a non-invasive, non-radioactive test for exocrine pancreatic insufficiency. Accuracy and clinical validity were examined with reference to both the secretin pancreozymin test and faecal fat analysis.

METHODS

A secretin pancreozymin test and faecal fat analysis were performed in 46 patients, 30 with exocrine pancreatic insufficiency and 16 with normal pancreatic function. In all of these patients and in seven healthy volunteers (controls), a 13C-Hiolein breath test was performed using 2 mg/kg [U-13C] labelled Hiolein with a standard risk snack (1.5 g/kg; 25% fat). 13CO2/12CO2 enrichment in the exhaled breath was measured by isotope ratio mass spectrometry.

RESULTS

In patients with pancreatic steatorrhoea the 13CO2 response was below the 95% confidence interval of 13CO2 exhalation in the controls. These responses were also diminished (p < 0.001) compared with patients with impaired lipase output but normal fat excretion and with disease as well as healthy controls. There was a linear correlation between stimulated lipase output and the ratio of lipase output/13CO2 response (r = 0.95). Among the 40 patients in whom direct pancreatic function testing was clinically indicated, the sensitivity of the 13C-Hiolein test for detecting steatorrhoea was 91.7%, with a specificity of 85.7%.

CONCLUSIONS

In patients with pancreatic disease the 13C-Hiolein breath test reflects impaired lipase output and indicates decompensated lipolysis. The 13C-Hiolein breath test is a convenient alternative to faecal fat analysis.