Influence of antacid and formulation on effectiveness of pancreatic enzyme supplementation in cystic fibrosis

A series of treatment trials, involving food balances based on determination of fat coefficient absorption, nitrogen faecal loss, and daily faecal weight, was performed in 82 patients with cystic fibrosis. Results showed that a conventional powdered pancreatic extract (Pancrex V) required a high dosage to achieve reasonable improvement in fat and nitrogen absorption (200 mg/kg body weight/day on average) and rarely restored digestion to normal. Bicarbonate (5.2 g/m2 body surface/day) slightly enhanced the enzymatic activity of the powdered extract, this being more apparent in those with more severe steatorrhoea. There was no advantage in providing the extract in microgranules protected by cellulose acetatephthalate. A product based on fungal lipase and protease (Krebsilasi) proved to be ineffective in correcting fat and protein absorption. The two recent products prepared in pH sensitive microspheres (Pancrex V microspheres and Pancreas-Prolipase) had similar advantages in digestive activity. Compared with the traditional preparations, they offered a number of practical advantages, including a smaller number of capsules (particularly Pancrex V microspheres) and improved palatability.

[Use of andekalin in treating diabetic microangiopathies]

A combined study of the state of the blood kinin, coagulation and fibrinolytic systems and microcirculation in the peripheral microvessels of 19 patients with diabetic microangiopathies has shown a diverse nature of disorders of kininogenesis (the enhancement or weakening of the process) and corresponding to it hypo- and hypertonic stages of changes of microcirculation in the microvessels of the eyeball and I toe nail matrix. Activation of blood coagulation, Phase I, revealed both in weakened and enhanced kininogenesis, was more noticeable in the phase of hypokininemia. The administration of andekalin at a single dose of 0.6 units per 1 kg of body mass against a background of sugar reducing therapy in both types of disorders of the activity of the kinin system was accompanied by an insignificant increase in the activity of plasma callicrein but resulted in a marked increase in the initially lowered kinin destroying blood enzymes. The improvement of some indices of microcirculation was noted but in patients with microangiopathies against a background of the weakening of kininogenesis. The administration of andekalin with an enhanced process resulted in some cases in the deterioration of the condition and development of perivascular edema. Insufficient therapeutic efficacy of commonly used doses of andekalin was determined by the presence of andekalin agents in commercial samples and admixtures of a considerable amount of kininases of tissue origin. Proceeding from the earlier experiments and ongoing clinical trials it was proposed that andekalin should be administered to patients with suppressed activity of the blood kinin system only at doses which would not practically contain kininases and would correspond to 0.004-0.005 units per 1 kg of body mass a day.

Pancreatic steatorrhea: action of a total lyophilized pancreas preparation: an "in vitro" and "in vivo" study

A total lyophilized pig pancreas (TLP) preparation was assayed "in vitro" and "in vivo". Lipase activity of the four lots studied was 6.180 +/- 1.122 IU by gram of the commercial product. There was no free trypsin detectable in the preparation. Fifteen pancreatic exocrine insufficiency patients were studied in a period of four weeks. Adult patients received from 35.500 to 35.776 IU of lipase contained in TLP preparation by meal. All patients had their steatorrhea reduced, or normalized, stool weight reduced and body weight increased. There is not an obligatory relation between stool fat loss and stool weight. Steatorrhea decreased at least during the 14 first days of treatment before reaching a stable level. This long delay before reaching a maximum effect deserves to be known: to test the efficiency of a pancreatic extract, the treatment must be given at least two weeks before estimating its results on fecal fat excretion.

The nutritional management of children with cystic fibrosis

Recently the need for low-fat diets in the treatment of cystic fibrosis has been questioned. Current ideas on the dietary treatment of the disease are discussed and the need to assess each patient individually is stressed. Supplementary feeding may be necessary to promote weight gain.

Elevated fasting cholecystokinin levels in pancreatic exocrine impairment: evidence to support feedback regulation

Previous studies have suggested that intraduodenal protease suppression of pancreatic exocrine secretion may be mediated through cholecystokinin (CCK) release. Our study compares basal plasma immunoreactive CCK concentrations in normal human subjects with those obtained in patients with chronic pancreatitis. Fasting plasma samples were collected from 18 normal subjects and from 18 patients with chronic pancreatitis. Eight patients had mild to moderate pancreatic exocrine impairment, and 10 had severe exocrine insufficiency. Venous plasma immunoreactive CCK concentrations were measured with two distinct peptide region-specific antibodies. Basal plasma CCK concentration in controls was 14.3 +/- 1.3 fmol/ml (mean +/- SEM), a value significantly less than that obtained in all patients with chronic pancreatitis, 30.1 +/- 4.0 fmol/ml (p less than 0.001). Patients with mild to moderate impairment had a fasting plasma CCK concentration of 32.8 +/- 7.9 fmol/ml (vs. control p less than 0.01), and those with severe disease 27.9 +/- 3.6 fmol/ml (vs. control p less than 0.001). In five patients with mild to moderate impairment of exocrine function and pancreatic extract-responsive abdominal pain, there was a 39 +/- 11% decrease in basal CCK levels during extract therapy (p less than 0.05). Results of this study indicate that pancreatic exocrine impairment is associated with elevated basal CCK levels, which may reflect a failure to provide feedback downmodulation of CCK release.

Protease-specific suppression of pancreatic exocrine secretion

The purposes of this study were to (a) evaluate the effect of pancreatic extract administered to patients with chronic pancreatitis and recurrent abdominal pain in a placebo-controlled, double-blind crossover study, (b) investigate the effects of acute intraduodenal pancreatic enzyme perfusion on pancreatic secretion, and (c) assess the effect of chronic, noninterrupted pancreatic extract administration on basal and stimulated pancreatic secretion. These studies demonstrated that pancreatic extract decreases abdominal pain and that intraduodenal perfusion with proteases but not with amylase or lipase suppresses pancreatic exocrine secretion in patients with chronic pancreatitis. Chronic administration of pancreatic extract to patients with chronic pancreatitis decreased both basal and stimulated pancreatic exocrine secretion.

Effect of pancreatic extracts on the faecal excretion and on the serum concentration of cobalamin and cobalamin analogues in cystic fibrosis

A malabsorption of crystalline labelled cobalamin is observed in 100% of cystic fibrosis patients. Using radioisotope dilution assays and molecular sieve gel chromatography, we determined the serum concentration and the faecal excretion of cobalamin and cobalamin analogues in nine cystic fibrosis children before and after 4 days' interruption of pancreatic extract treatment. On chromatography, the unsaturated cobalamin binders of the faecal extracts eluted in two positions with molecular masses of 44 300 and 20 300, corresponding mostly to partially degraded R binders. The amounts of the less degraded form of R binder (molecular mass 44 300) increased significantly after interruption of the treatment. The cobalamin concentration in the serum remained normal after interruption of the treatment but the analogue concentrations in the serum decreased and faecal excretion of cobalamin and analogues increased significantly. These results allowed us to suggest that (1) pancreatic insufficiency in cystic fibrosis is responsible for a decrease in the absorption of digestive analogues induced by a defective degradation of R binders, and (2) cobalamin analogues have a short half-life in blood.

Pancreatic supplementation in end-stage renal disease

The common occurrence of a wasting syndrome in patients with end-stage renal disease (ESRD) on haemodialysis indicates the need for nutritional management. Pancreatic hypofunction has been documented in these patients, and is suggested as a contributory factor to the wasting of ESRD. The patient presented illustrates the presence of pancreatic disease, and details his management. The advantages of pancreatic supplementation in improving nutritional status in ESRD are considered.

Assessment of weight loss, food intake, fat metabolism, malabsorption, and treatment of pancreatic insufficiency in pancreatic cancer

In 12 patients with biopsy-proven pancreatic ductal adenocarcinoma, the following were determined: (1) whether decreased food intake, malabsorption, or altered fat metabolism were associated with weight loss; (2) the effect of pancreatic extract as treatment for malabsorption; and (3) the accuracy of the triolein breath test for detection of steatorrhea. Weight loss occurred in 11 patients and only in patients who had either malabsorption (n = 5), low coefficients of caloric consumption (n = 2), or both (n = 4). Nine patients had fat malabsorption, six had protein malabsorption, and caloric consumption was decreased in seven patients. Metabolism of oleic acid was significantly decreased (P less than 0.01) compared to normal subjects and correlated with basal metabolic rates (r = 0.6; P less than 0.05) which were within the range of normal values for age and sex. Body weight loss correlated only with coefficients of fat and protein absorption (r = 0.59; P less than 0.05). Treatment of patients with pancreatic extract resulted in significant improvement in absorption in those with moderate to severe fat or protein malabsorption (coefficient of absorption less than 80%) but no significant improvement occurred in patients with mild fat or protein malabsorption. The triolein breath test was abnormal in all patients with fat malabsorption and predicted improvement of fat absorption in five of six patients with steatorrhea who were treated with pancreatic extract. Thus, in pancreatic cancer, weight loss is associated with malabsorption; exogenous pancreatic extract significantly improves moderate to severe fat or protein malabsorption, and the triolein breath test detects fat malabsorption and predicts the treatment response to pancreatic extract.