Pancreatobiliary responses to an intragastric amino acid meal: comparison to albumin, dextrose, and a maximal cholecystokinin stimulus

Little is known about how gastric and pancreatobiliary responses differ after intake of elemental diets from responses to polymeric food. We therefore compared pancreatic and biliary secretions after gastric instillation of albumin (7 g%, with dextrose 21 g%) with an elemental diet in 6 healthy volunteers. The elemental diet contained amino acids (7 g%, with dextrose 21 g%) in the same molar composition as the albumin. Furthermore, we studied the effect of a pure intragastric dextrose solution (21 g%) on pancreatobiliary secretions, as glucose constitutes a major component of elemental diet formulas. The various pancreatobiliary responses were tested against a maximal i.v. cholecystokinin stimulus. The dextrose, amino acid, and albumin meals emptied at similar rates, and gastric emptying was completed within 3 h. Similar pancreatobiliary responses were observed after the albumin and amino acid meals, but response to both the amino acid and albumin meals was smaller than to the intravenous cholecystokinin stimulus. The glucose meal caused a marked and sustained stimulation of pancreatobiliary outputs, which did not differ significantly from the other test meals. However, lower cholecystokinin levels were observed after the glucose meal compared with distinct cholecystokinin release after the albumin and amino acid meals. We conclude first that there are no major differences in secretory responses between elemental (amino acid) and polymeric (protein) meals and second, that intragastric pure glucose meals strongly stimulate pancreatobiliary secretions. The marked pancreatic and biliary responses to intragastric dextrose cannot be fully explained on the basis of cholecystokinin release, suggesting that this response is probably mediated by neural mechanisms.

GIP and insulin release in relation to gastric emptying of a mixed meal in man

To clarify the role of GIP (gastric inhibitory polypeptide) as an incretin, we related temporally the gastric emptying of fat, protein and glucose to plasma levels of glucose, GIP and insulin in man. Five healthy volunteers with a multiple lumen duodenal tube ingested a mixed meal with phase-specific markers for the aqueous phase, liquid fat and the solid protein phase. Duodenal passage was determined by intraduodenal infusion of a second set of phase-specific non-absorbable markers. Plasma insulin rose rapidly from a basal value of 59 pM to 300 pM at 60 min, and then declined to reach basal levels after 180 min. By contrast, plasma GIP rose more slowly than insulin, from a basal value of 9.4 pM, and remained elevated, in the range of 14-18 pM, throughout the 240 min observation period. The time course of plasma insulin concentration paralleled gastric emptying of the aqueous phase, containing most of the meal's glucose (r = 0.952, P less than 0.001). The time course of plasma GIP concentrations paralleled the gastric emptying of fat and protein (r = 0.763-0.834; P less than 0.01-0.05). Plasma insulin concentrations showed no correlation to the rate of emptying of fat and protein (r = 0.142-0.420; n.s.) and to plasma levels of GIP (r = 0.365; n.s.). The threshold for plasma glucose at which GIP would exert an incretin effect only reached at one time point, 30 min after ingestion of the meal. Our findings of simultaneously tracked gastric emptying of meal nutrients, hormone release and plasma glucose levels do not support an important physiological role for GIP as an insulinotropic hormone after ingestion of mixed meals in man.

Estradiol induces rapid remodelling of plasma membranes in developing rat cerebrocortical neurons in culture

Exo-endocytotic images and intramembrane particles were quantitatively assessed in freeze-fracture replicas from the plasma membrane of dispersed fetal rat cortical neurons (day 16 gestation) grown for 24 days in culture. The addition of 10(-10) M 17 beta-estradiol to the culture medium resulted in a significant increase in the numerical density of exo-endocytotic images within 1 min. A further increase of the number of exo-endocytotic images associated to a significant decrease in the number of intramembrane particles was observed in cells exposed for 10 min to 17 beta-estradiol. Similar results were observed when the cells were exposed to 17 beta-estradiol for 17 days. No effects on exo-endocytotic images and intramembrane particles were observed when 17 alpha-estradiol was added, instead of 17 beta-estradiol, to the cultures. These results indicate that physiological levels of 17 beta-estradiol can have rapid effects upon the ultrastructure of the neuronal membrane of developing cerebrocortical neurons.

Intraluminal calcium binding does not mediate fatty acid-induced pancreatic bicarbonate secretion

Since the chain length dependency of fatty acid-induced pancreatic exocrine secretion parallels that of fatty acid-induced inhibition of gastric emptying, similar mechanisms of action may be involved. An earlier study suggested that binding of calcium might mediate fatty acid-induced inhibition of gastric emptying. This study investigated possible mediation of fatty acid-induced pancreatic secretion by calcium binding. Pancreatic secretory response to intraduodenal administration of dodecanoate and various calcium chelators (sodium EDTA, calcium-saturated EDTA, sodium dodecyl sulfate, sodium dioctyl sulfosuccinate, and sodium taurocholate) was studied in three dogs equipped with chronic pancreatic fistulae. Calcium affinity of the various test solutions was quantitated by titrating aliquots of perfusate against a standard CaCl2 solution. Sodium EDTA was found to be the most potent calcium binder (pKc 8.3); sodium dodecanoate, sodium dodecyl sulfate, and sodium dioctyl sulfosuccinate were moderate calcium binders (pKc 7.3, 7.2, 6.9, respectively), whereas sodium taurocholate and calcium-saturated EDTA were poor calcium binders. Sodium dodecanoate evoked brisk bicarbonate output (0.6-1.6 mEq/15 min). Minimal secretory responses were observed in response to all other agents tested. These findings suggest that calcium binding is not involved in mediation of fatty acid-induced pancreatic bicarbonate secretion.

Inhibition of gastric emptying by glucose depends on length of intestine exposed to nutrient

Nutrients inhibit gastric emptying in a dose-related fashion. We postulated that load-dependent gastric emptying results from the saturation of mucosal absorptive mechanisms, so that a longer length of the small intestine is exposed to unabsorbed nutrients as more nutrient enters the intestine to participate in this negative feedback. To test this idea, we limited exposure of 0.25 to 1.0 M glucose meals to various lengths of duodenum and jejunum in 17 dogs. The effects of these limited perfusions were then compared with experiments in which the whole gut (ALL) was exposed to the nutrient. Maximal inhibition was seen with 1.0 M meal and was similar with perfusions of 150 cm and ALL. By contrast, even with the 1.0 M load, no inhibition of gastric emptying was seen when glucose meal was confined to the first 15 cm of the proximal duodenum. Only 50-60% of maximal inhibition was observed during confinement of 1.0 M meal to the proximal 65 cm. We concluded that glucose sensors are present in both the proximal and the distal gut and the inhibition was related to the length of the small intestine exposed to glucose.

Influence of the organophosphorus compound DFP on inhibitory motor systems and esterase activity in the spinal cord of cats

In high spinal cats, the acute time-dependent changes of both the activity of spinal reflex pathways and the activity of three different esterases (acetylcholinesterase, carboxylesterase and neurotoxicant target enzyme) in the spinal cord were investigated after intravenous application of the organophosphorus compound di-isopropyl phosphofluoridate (DFP). There is no general depression of spinal reflexes by DFP. While the recurrent inhibition is completely abolished for a long time and the reflexes to a flexor (PBSt) are depressed but with a shorter recovery time, the reflexes to an extensor (GS) are distinctly less depressed or even facilitated. Reflex pathways from skin afferents to motoneurones did not react in a uniform way to DFP, e.g. inhibitory nociceptive pathways were less affected than excitatory ones. Esterase activities were heavily depressed and recovered with different time courses. The acute DFP action cannot be explained by a uniform intoxication of all spinal functions but probably emerges from a differential action on different interneuronal systems.

Transient dyserythropoiesis occurring during the involutionary phase of stage IV-S neuroblastoma

An acutely ill 6-month-old female infant presented with massive hepatomegaly, accompanied by severe anemia with peripheral normoblastemia and thrombocytopenia. Bone marrow examination revealed erythroid hyperplasia with gross erythroid dysplasia, reduced granulocytic precursors, and virtually absent megakaryocytes. The bone marrow also contained completely necrotic cells occurring in clumps as well as singly. The appearances suggested bone marrow involvement by neuroblastoma. Accordingly, combination chemotherapy was instituted and laparotomy was performed as soon as her clinical condition had improved. Left adrenalectomy was carried out, because a small adrenal nodule of ganglioneuroma was present. Liver biopsy showed expansion of portal tracts by loose fibrous connective tissue containing hemosiderin deposits and some degenerate cellular debris, consistent with areas of involuted metastatic neuroblastoma. Complete recovery followed, and subsequent bone marrow examination was entirely normal. It is thought that the dyserythropoiesis probably resulted from the release of toxic metabolites from regressing neuroblastoma.

The effect of bile diversion on satiety and fat absorption from liquid and solid dietary sources

In previous studies, liquid fat has been used to determine the effect of bile diversion on fat absorption. Since protein digests, in addition to bile salts, are capable of solubilizing lipids, we hypothesized that fat incorporated in the protein-rich matrix of solid food would be less sensitive to bile diversion than fat ingested as an oil or liquid. Using [3H]glycerol triether as a nonabsorbable fat recovery marker, we determined how much [14C]triolein was absorbed from solid (chicken liver) and liquid (margarine) dietary sources. After a standard liquid/solid meal with either the chicken liver or margarine labeled, midintestinal chyme was collected for 6 hr, extracted, and counted for 14C and 3H activity. Zero, eighty, or one hundred percent of endogenous bile was diverted. Fat absorption from both chicken liver and margarine was nearly complete by midintestine with 0% diversion and was little affected by diversion of 80% of bile. Complete biliary diversion significantly decreased fat absorption from margarine (87.9 +/- 4.4 to 37.2 +/- 9.2%, P less than 0.05) but reduced [14C]triolein absorption from chicken liver less consistently and insignificantly (78.8 +/- 6.9 to 43.9 +/- 10.6%). These data indicate that fat absorption is not solely dependent on bile and support the hypothesis that fat ingested in a cellular matrix is less dependent on bile than liquid fat. Using these same animals but with the midintestinal cannulas plugged to expose the distal intestine to unabsorbed luminal nutrients, we also demonstrated that bile diversion of an initial meal reduced food consumption at a meal offered 3 hr later.

Temporal relationships of cholecystokinin release, pancreatobiliary secretion, and gastric emptying of a mixed meal

The influence of gastric emptying of nutrients on plasma cholecystokinin and pancreatobiliary functions is poorly understood. We therefore temporally related the emptying of fat, protein, and glucose of a mixed meal to release of the gut hormones cholecystokinin, pancreatic polypeptide, and peptide YY and outputs of trypsin, lipase, bilirubin, and bile salts. Five healthy volunteers with a multilumen duodenal tube ingested a mixed meal with phase-specific markers for the aqueous phase, liquid fat, solid fat, and solid protein phases. Duodenal passage was determined by intraduodenal infusion of a second set of phase-specific nonabsorbable markers. Plasma cholecystokinin levels and pancreatobiliary secretions rose to a maximum at 30-60 min and then gradually declined (p less than 0.01) despite continued entry of protein and fat into the duodenum throughout the whole 4-h experimental period. High levels of both pancreatic polypeptide and peptide YY were observed in the last 2 h of the experiment. Release of factors capable of inhibiting cholecystokinin release and subsequently pancreatobiliary secretion may be responsible for the observed time-course.

Duodenal instillation of pancreatin does not abolish steatorrhea in patients with pancreatic insufficiency

Many believe that intragastric deactivation of lipase accounts for the frequent failure of orally ingested pancreatic enzymes to normalize fat absorption in patients with pancreatic insufficiency. To test this hypothesis, we measured fat absorption from a large test meal in six patients with pancreatic insufficiency after we had instilled Viokase directly into the postcibal duodenum in two doses, one to deliver lipase at about 10% of normal secretory rates and the other at four times this rate. Direct duodenal instillation of neither the low nor the high dose of Viokase, nor the low dose of Viokase plus sodium bicarbonate, normalized fat absorption from the test meal; none of these duodenal instillations significantly improved fat absorption over that after the test meal plus orally ingested Viokase. Despite these various treatments, the patients excreted an average of 25.5 g of dietary fat as opposed to 2.1 g excreted by six normal subjects after the same meal. We conclude that more than just intragastric destruction of lipase underlies the frequent failure of orally ingested pancreatin to normalize fat absorption in pancreatic insufficiency.

Indolent presentation of pancreatic abscess. Experience with 100 cases

One hundred cases of pancreatic abscess were identified at five hospitals affiliated with UCLA between 1973 and 1985. Patients were included if a pancreatic mass or phlegmon followed an episode of pancreatitis, if the clinical impression was pancreatic abscess, and if drainage cultures were positive. Less than three Ranson's signs were present on admission in 72% of patients. The admission temperature was less than 38.3 degrees C in 71% of patients, and 27% of patients never had a fever. Abdominal tenderness was absent in 40% of patients. The admission amylase concentrations and white blood cell counts were normal in 36% and 23% of patients, respectively. Extensive débridement, external drainage, and a low threshold for reoperation were the mainstays of surgical therapy. Twenty patients (20%) died, but Ranson's signs did not predict outcome. pancreatic abscess may have an insidious presentation. A high index of suspicion, early computed tomographic scanning, and diagnostic needle aspiration may be necessary to establish this diagnosis.

Intragastric vs intraintestinal viscous polymers and glucose tolerance after liquid meals of glucose

To determine whether viscous fibers improve glucose tolerance by slowing gastric emptying or impeding intestinal uptake of glucose, 800 mL of 0.2 mol glucose/L were instilled into the stomachs of the dogs and allowed to empty from the stomach out the proximal limb of a duodenal fistula while simultaneously fresh solution was instilled into the distal duodenum at the same rate. This technique allowed us to study 33 g pectin/L, isoviscous 400 g PEG 20,000/L, or 11 g guar/L when present with glucose in the stomach only, the intestine only, or in both stomach and intestine. Rates of gastric emptying and plasma glucose were lower when viscous polymer was present at both sites than at either site separately. Slowing of gastric emptying was an interactive outcome of viscosity at both loci, probably from slowed intestinal absorption of glucose with its exposure to more intestinal sensors. Reductions in postcibal glucose concentrations depended on slowing of both gastric emptying and intestinal absorption.

GI transit and absorption of solid food: multiple effects of guar

These experiments were undertaken in dogs with midintestinal fistulas to determine whether guar added to a meal of solid food would disrupt gastric sieving and give rise to maldigestion of solid food. Dogs were fed a standard meal of steak, chicken liver, bread, margarine, and water in which there was 0, 3.3, 7.5, or 15 g guar powder. The margarine or the liver contained [14C]triolein. Using an isotope ratio method, we determined how much [14C]triolein was absorbed at midintestine. We found that guar in a dose-related fashion increased the weight of chyme collected at midintestine, markedly reduced the percent of triolein absorbed by midintestine from 88 to 38%, and profoundly increased the passage to midintestine of large, poorly digestible pieces of steak and liver. The viscosity of the guar promoted the GI transit of large, poorly digestible pieces of food but also reduced absorption by other mechanisms.

Release of secretin along the canine small intestine

The profile of secretin release along the entire canine small intestine was examined in this study. Four equal loops of the small gut, from the duodenal bulb to the ileocoecal valve, were isolated. In eight anesthetized dogs the four segments were perfused for 40 min each in random order with an acidified (pH 2.5) emulsion of 20 mM oleic acid. In four dogs control experiments were performed using 0.15 M saline. Secretin release in portal venous blood was measured by a sensitive radioimmunoassay. Although secretin was mainly released in the first quarter of the small intestine (310 pM X 40 min), large amounts of secretin, 33% of the total secretin release, were liberated in the second quarter of the small intestine (164 pM X 40 min). Minute amounts of secretin (23 pM X 40 min) were released in the third quarter, whereas perfusion of the last quarter of the small gut failed to release secretin. We conclude that the major portion of secretin is releasable in the first quarter of the small gut. High amounts of secretin can be liberated in the second quarter of intestine, an area that is probably never exposed to pH below 4.5 (the known threshold for secretin release by acid), but is still exposed to fatty acids (other releasers of secretin).

Human postprandial gastric emptying of 1-3-millimeter spheres

Microspheres of pancreatin should empty from the stomachs of patients with pancreatic insufficiency as fast as food. The present study was undertaken in 26 healthy subjects to identify the size of spheres that would empty from the stomach with food and to determine whether different meals alter this size. Spheres of predefined sizes were labeled with 113mIn or 99mTc. Using a gamma-camera, we studied the concurrent gastric emptying of spheres labeled with 113mIn and of chicken liver labeled with 99mTc in 100-g, 154-kcal or 420-g, 919-kcal meals, or the concurrent emptying of 1-mm vs. larger spheres. One-millimeter spheres emptied consistently (p less than 0.01, paired t-test) faster than 2.4- or 3.2-mm spheres when ingested together with either the 420- or 100-g meals. Thus, in the 1-3-mm range of diameters, sphere size was a more important determinant of sphere emptying than meal size. Statistical analyses indicated that spheres 1.4 +/- 0.3 mm in diameter with a density of 1 empty at the same rate as 99mTc-liver. Our data indicate some commercially marketed microspheres of pancreatin will empty too slowly to be effective in digestion of food.

Effects of captopril on survival in patients with heart failure

Results from a large multicenter study and from the published literature suggest that captopril can improve survival in patients with advanced heart failure. The survival status of 105 patients with moderately severe heart failure who participated in a multicenter, double-blind comparison of captopril and placebo therapy was ascertained on an intention-to-treat basis. During the 90-day double-blind portion of this study, 21 percent (11 of 52 patients) of placebo-assigned patients died compared with four percent (two of 53 patients) of captopril-assigned patients (p less than 0.01). In addition, six previously published studies that provided comparative mortality data were identified. In one of these, the survival rate was reported to be improved in those who received captopril; in the other five studies, no conclusion could be drawn with respect to survival since death was an infrequent event within all treatment groups. Mechanisms by which captopril may improve survival include its favorable effects on hemodynamic parameters, its association with reduced ventricular ectopic activity, and its inhibitory effects on the renin-angiotensin and sympathetic nervous systems.

Vagotomy and antrectomy impairs canine fat absorption from solid but not liquid dietary sources

Mild steatorrhea is common after all ulcer operations except parietal cell vagotomy. As these operations impair the grinding and sieving of solid food, we sought to determine the effect of vagotomy and antrectomy on fat absorption from solid (e.g., liver) as compared with liquid (e.g., margarine) dietary sources in the proximal small intestine. Midgut fistulas were placed in 13 dogs; 7 were controls and 6 underwent concurrent vagotomy and antrectomy. To label solid fat, the livers of live chickens were labeled with intravenous [14C]triolein and [3H]glycerol triether, an absorbable and nonabsorbable fat label, respectively. For the liquid fat label, these markers were mixed with margarine. A standard meal of steak, liver, bread, margarine, and water, with either the liver or margarine fat labeled, was fed and the midgut effluent was sieved and centrifuged to obtain four phases: large particles (greater than 0.5 mm), small particles (less than 0.5 mm), aqueous, and oil, which were extracted and counted for 14C and 3H. The ratio of 14C to 3H in each fraction was used to determine how much fat was absorbed from each phase of chyme. With liver fat labeled, 48.3% +/- 8.1% of the [3H]glycerol triether remained in large particles after vagotomy and antrectomy compared with 3.1% +/- 1.0% in controls at midintestine (p less than 0.001). After vagotomy and antrectomy, more than half of the liver fat (solid fat) was malabsorbed (57.1% +/- 6.5% vs. 23.1% +/- 6.6% malabsorbed, p less than 0.01, vagotomy and antrectomy vs. controls), whereas fat absorption from margarine (liquid fat) was not reduced compared with controls (8.8% +/- 2.5% vs. 13.6% +/- 5.5% malabsorbed, p greater than 0.05, vagotomy and antrectomy vs. controls). These observations indicate that by reducing gastric trituration and releasing large particles of poorly digested food into the intestine, vagotomy and antrectomy impairs the absorption of fat selectively from solid, but not from liquid, dietary sources.

Passage of salivary amylase through the stomach in humans

With an inhibitor assay technique rates of passage of salivary and pancreatic isoamylase through the jejunum were measured in six healthy volunteers after different liquid, intragastric meals. In all subjects and in 13/17 experiments, more than 2500 units of salivary amylase were passed over 200 postcibal minutes. Salivary amylase comprised 13.8 +/- 3.9% (mean +/- SEM) of the total amylase and appeared predominantly as single, distinct peak. The inhibitor method was validated by isoelectric focusing (r = 0.988; P less than 0.001; N = 7). The frequency of detection of salivary amylase in gastric or jejunal samples fell as gastric pH fell below 3.0. In vitro, amylase was inactivated in gastric juice as pH fell between 3.8 and 3.3. Salivary amylase accounted for 11% of total amylase output in a normal and 27% in an achlorhydric subject after a hamburger meal. We conclude that amylase should not be measured in postprandial studies of pancreatic secretion in humans without correction for salivary amylase.

Comparison of gastrointestinal pH in cystic fibrosis and healthy subjects

The primary objective of this study was to define the pH conditions under which supplemental pancreatic enzyme preparations must function in the upper gastrointestinal tract. The hypothesis was that normal or greater acid output in patients with cystic fibrosis (CF), combined with low pancreatic bicarbonate output, results in an acidic duodenal pH, compromising both dosage-form performance and enzyme activity. Gastrointestinal pH profiles were obtained in 10 CF and 10 healthy volunteers under fasting and postprandial conditions. A radiotelemetric monitoring method, the Heidelberg capsule, was used to continuously monitor pH. Postprandial duodenal pH was lower in CF than in healthy subjects, especially in the first postprandial hour (mean time greater than pH 6 was 5 min in CF, 11 min in healthy subjects, P less than 0.05). Based on the dissolution pH profiles of current enteric-coated pancreatic enzyme products, the duodenal postprandial pH in CF subjects may be too acidic to permit rapid dissolution of current enteric-coated dosage forms. However, the pH was above 4 more than 90% of the time on the average, suggesting that irreversible lipase inactivation in the duodenum is not likely to be a significant limitation to enzyme efficacy. Overall results suggest that slow dissolution of pH-sensitive coatings, rather than enzyme inactivation, may contribute to the failure of enteric-coated enzyme supplements to normalize fat absorption.

Hormone-induced and maturational changes in electric organ discharges and electroreceptor tuning in the weakly electric fish Apteronotus

Plasticity in the frequency of the electric organ discharge (EOD) and electroreceptor tuning of weakly electric fish was studied in the genus Apteronotus. Both hormone-induced and maturational changes in EOD frequency and electroreceptor tuning were examined. Apteronotus is different from all other steroid-responsive weakly electric fish in that estradiol-17 beta, rather than androgens, induces discharge frequency decreases. This result can account for the 'reversed' discharge frequency dimorphism found in Apteronotus in which, counter to all other known sexually dimorphic electric fish, females have lower discharge frequencies than males. Studies of electroreceptor tuning in Apteronotus indicate that electroreceptors are closely tuned to the frequency of the EOD. This finding was noted not only in adult animals, but also in juvenile animals shortly after the onset of their EODs. Tuning plasticity in Apteronotus, as in other species studied, is associated with altered EOD frequencies and was noted in both maturational EOD changes and in estrogen-induced changes. Thus, tuning plasticity appears to be a general phenomenon which occurs concurrent with a variety of EOD changes.

Gastric emptying of liquids in normal subjects and patients with healed duodenal ulcer disease

We have characterized the dose-response of inhibition of gastric emptying by acid, glucose, and fat in duodenal ulcer (DU) patients and normals (N) matched by age and sex. Gastric emptying was measured by the George technique while intragastric pH was maintained constant by intragastric titration. Acid, glucose, and fat inhibited gastric emptying in a dose-dependent fashion in both groups. DU patients emptied all three types of meals faster than normals, but differences were only seen at the lower doses of glucose or with the less potent doses of acid and fat. With low concentrations of glucose and at all concentrations of acid, DU patients emptied the meals faster than normals only in the first 5 min; but with fat the differences persisted throughout the 30-min test. Differences in gastric emptying of liquid meals in DU patients vs normals are small, and they occur with nutrient as well as acid meals. The variable responses obtained with the different concentrations may explain the inconsistencies found by other workers.