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.

Metal-binding ligands in Viokase

The object of this study was to detect low molecular weight zinc binders in Viokase, a porcine pancreatic preparation used in the treatment of variant acrodermatitis enteropathica (AE). Extracts were centrifuged and ultrafiltered to yield a soluble fraction containing solutes of molecular weights less than or equal to 500 daltons. These were studied by modified gel chromatography (MGC) using sealed Sephadex G-15-120 columns equilibrated with buffered solvent systems containing either 5 ppm copper (II) or 5 ppm zinc (II). Eluted fractions were assayed for these metals by atomic absorption and for amino acids by various techniques. MGC profiles of ultrafiltrates resulted in a peak consisting of glutamic acid and another peak consisting of several amino acids. A third peak was due to metal ions. Citrate and picolinate have been claimed to be important zinc-binding ligands in Viokase, but neither was detectable by MGC, although small amounts of citrate or similar compounds were detected by the Furth and Herrmann reaction. Since amino acid ligands are easily detectable by MGC, and metal distribution among ligands is competitive in nature, the possibility of a role for citrate or picolinate as a zinc transporter in Viokase is seriously reduced. Relief to the variant AE patient was probably not due to citrate- or picolinate-enhanced zinc uptake.

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.

Incidence of distal intestinal obstruction syndrome in cystic fibrosis

A variety of intestinal complications, including constipation, abdominal pain, palpable cecal masses, intestinal obstruction, intussusception, and volvulus, have been observed beyond the neonatal period in patients with cystic fibrosis (CF). In a retrospective chart review of 63 patients with CF, we found evidence of one or more of these complications in 26 patients (41.3%). The incidence of intestinal complications was not related to overall disease severity, pulmonary exacerbations, history of meconium ileus at birth, or dose or type of pancreatic enzyme replacement. There was no change in the incidence of intestinal complications after patients switched to a pH-sensitive enteric-coated microsphere enzyme preparation.

Comparative evaluation of the therapeutic efficacy of a pH-sensitive enteric coated pancreatic enzyme preparation with conventional pancreatic enzyme therapy in the treatment of exocrine pancreatic insufficiency

The therapeutic efficacy of a pH-sensitive enteric coated pancreatic enzyme preparation was compared with conventional pancreatic enzyme preparations in 6 adult patients with exocrine pancreatic insufficiency. Fecal fat excretion and postprandial duodenal recovery of orally ingested pancreatic enzymes were evaluated after ingestion of each preparation. Fecal fat excretion decreased significantly (p less than 0.005) on treatment with pH-sensitive and conventional pancreatic enzyme preparations. Postprandial concentration and delivery of trypsin and lipase in samples aspirated from duodenojejunal junction were higher after ingestion of conventional pancreatic enzyme preparation as compared to the pH-sensitive enteric coated preparation. The difference, however, did not reach statistical significance. Our observations suggest that the pH-sensitive enteric coated pancreatic enzyme preparation is only as effective as conventional pancreatic enzyme preparations in controlling fat malabsorption in patients with exocrine pancreatic insufficiency. Failure of pH-sensitive enteric coated preparation to deliver greater quantities of pancreatic enzymes at duodenojejunal junction is most likely related to the impaired release of enzymes from microspheres due to low intraluminal pH in the upper small intestine in pancreatic insufficiency.

Pain reduction by an oral pancreatic enzyme preparation in chronic pancreatitis

In a double-blind study on 19 patients with the diagnosis of chronic pancreatitis, the effects of treatment with a granulated pancreatic enzyme preparation (Pankreon) were compared with those of placebo administration. One week of treatment with each preparation was preceded by one week without any medication. The patients kept daily records of their symptoms, plotting the severity of pain on an analog scale. Weekly assessments of the mean pain level were also made by an examiner questioning the patients. Recordings of body weights and pancreas and liver laboratory tests were done weekly. Fifteen of 19 patients noted less pain during the week of treatment with pancreatic enzymes as compared to that of placebo treatment (P less than 0.05). The average reduction of pain, as calculated for all patients, was 30% as evaluated by both patients (P less than 0.01) and the examiner (P less than 0.05). No differences were found in other parameters examined. A possible explanation of the findings could be an effect on the intraductal pressure by intraluminal trypsin.

[Chronic pancreatitis and diabetes]

Chronic pancreatitis appears to be increasing likely because increase in alcohol consumption and improved diagnostic tools. So the diabetes due to chronic pancreatitis is gaining importance. In order to obtain a better understanding of that particular secondary diabetes, 179 patients with chronic pancreatitis were studied from 1970 to 1981. 154 patients were male and 25 female. Average admission age was 45, ranging from 25 to 86. All the patients underwent medical therapy, based on diet, pancreatic enzymes, pain control. 99 of them underwent even to surgery. The follow-up is ranging from 6 months to 10 years: during this period 18 patients died, 41 went lost. 120 patients are still under observation. Diabetes was found in the family history of 27 patients (15%). At hospital admission 41 patients (23%) had high fasting glycemia, 23 of them even glycosuria. Other 74 showed diabetic oral glucose tolerance test. During the follow-up time 27 became clinically diabetic, 3 died because hyperosmolar coma and 8 had to be readmitted more than once because diabetic metabolic decompensation. Among the 120 patients at the moment under control, 66 (55%) show abnormal fasting glycemia, 10 developed high blood pressure, 12 inferior limbs vasculopathy with paresthesias and intermittent claudication, 2 myocardiosclerosis and atrial fibrillation, 1 myocardial infarction, 2 chronic nephropathy, 1 diabetic retinopathy. Whereas surgery or medic therapy may relieve chronic pancreatitis typical symptoms, they appear to be useless remedy against the under lying diabetes. As the time goes on more and more patients develop glucose intolerance, quite early became insulin-dependent, are disposed to severe diabetic metabolic decompensation and can show vascular, cardiac or renal complication.

Comparison of effectiveness of pancreatic enzyme preparations in cystic fibrosis

To evaluate claims that enteric-coated pancreatic enzyme preparations are more effective than conventional digestants in managing malabsorption in cystic fibrosis (CF), we conducted a trial comparing the efficacy of pancrealipase (enzyme supplement containing lipase, amylase, and protease) in the form of pH-sensitive microspheres (Pancrease) with that in the form of encapsulated enzyme powder (Cotazym). Ten boys with CF received equivalent dosages in a controlled, double-blind fashion using a random sequence of capsule administration with crossover and "washout" periods. Patients experienced significantly enhanced nitrogen and fat absorption while receiving either enzyme when compared with placebo. The enteric-coated product promoted significantly improved fat absorption as compared with the conventional enzyme capsule. Both enzyme preparations caused significantly improved protein absorption as compared with placebo, but there as no significant difference between the two products in the degree of effect on azotorrhea.

A clinical trial of amygdalin (Laetrile) in the treatment of human cancer

One hundred seventy-eight patients with cancer were treated with amygdalin (Laetrile) plus a "metabolic therapy" program consisting of diet, enzymes, and vitamins. The great majority of these patients were in good general condition before treatment. None was totally disabled or in preterminal condition. One third had not received any previous chemotherapy. The pharmaceutical preparations of amygdalin, the dosage, and the schedule were representative of past and present Laetrile practice. No substantive benefit was observed in terms of cure, improvement or stabilization of cancer, improvement of symptoms related to cancer, or extension of life span. The hazards of amygdalin therapy were evidenced in several patients by symptoms of cyanide toxicity or by blood cyanide levels approaching the lethal range. Patients exposed to this agent should be instructed about the danger of cyanide poisoning, and their blood cyanide levels should be carefully monitored. Amygdalin (Laetrile) is a toxic drug that is not effective as a cancer treatment.

A mixed-triglyceride breath test for intraluminal fat digestive activity

A new test of intraluminal fat digestive activity is proposed for which a mixed triglyceride, 1,3-dioleyl-2-14C-decanoyl glycerol, was used. 29 normal subjects, 14 patients with proven chronic pancreatitis, 10 pancreatectomy, 12 villus atrophy and 8 bile acid-deficient patients were studied. The mean 14CO2 excretion in breath, expressed as the 10th-hour cumulative percentage of the administered dose, was 68.3% in the normal subjects, and only 32.9% in patients with pancreatic disease. There was almost no overlap between the normal subjects and the patients with proven organic disease. The test also allowed the detection of functional pancreatic insufficiency, due to impaired pancreatic stimulation in case of gluten enteropathy and severe malabsorption.

Effectiveness of cimetidine as an adjunct to supplemental pancreatic enzymes in patients with cystic fibrosis

The effectiveness and safety of the use of cimetidine as an adjunct to pancreatic enzymes was evaluated in eight patients with cystic fibrosis having pancreatic insufficiency. Cimetidine (300 mg, three times a day) was given for a 6-week period during which the patients demonstrated a significant weight gain (P < 0.05) and reduction of steatorrhea (P < 0.01). Data suggesting an early correction of the abnormal fatty acid composition of plasma lipids were observed. No side effects were apparent during the clinical trial. These results demonstrate the beneficial effects of the use of cimetidine in patients with cystic fibrosis and indicate the need for long-term clinical trials.

Effect of cimetidine and sodium bicarbonate on pancreatic replacement therapy in cystic fibrosis

Fifteen patients with cystic fibrosis and pancreatic insufficiency were studied during four randomised seven day treatment periods in which they received only pancreatic supplement (Pancrelipase, 27 capsules per day) or supplement plus cimetidine (20 mg/kg body weight/24 h) or sodium bicarbonate (15 g/m2/24 h) alone or in combination. Dietary intake was not fixed but was restricted to foods of known fat and nitrogen content from which daily intakes could be computed. Faecal fat and nitrogen were calculated as g/24 h and percentage of intake. Addition of either cimetidine or bicarbonate resulted in significant improvement in fat and nitrogen excretion, which was not greater with the combination of both drugs. Cimetidine and sodium bicarbonate in these doses are therefore sufficient to produce maximal improvement in digestive activity of pancreatic supplements. Fat excretion per gram of intake fell with cimetidine and bicarbonate from 12 times the normal level, to normal, in patients consuming less than 120 g fat daily. Above this intake the dose of pancreatic supplement appeared to be inadequate. Faecal nitrogen excretion increased with nitrogen intake in all four periods, but, in contrast with fat excretion, the response to cimetidine and bicarbonate was not affected by the level of intake. Dietary intake appears to be a significant factor in determining the faecal output of fat and nitrogen in patients with pancreatic insufficiency and should be considered when determining the optimum amount of pancreatic supplementation.

Hyperuricosuria in cystic fibrosis patients treated with pancreatic enzyme supplements. A study of 16 patients in Israel

Uric acid metabolism was evaluated in 16 Israeli cystic fibrosis patients, all of whom were taking pancreatic enzyme supplements. The findings were compared with those in a recent study of uric acid metabolism in 65 healthy Israeli children. Hyperuricemia of 4.9 +/- 0.2 (SE) mg/dl was found in the cystic fibrosis patients, compared with a normal level of 3.1 +/- 0.2 mg/dl ( P < 0.05). In five patients, 24-h urine collections were assayed and all showed hyperuricosuria. Thirteen patients had high urinary uric acid/creatinine ratios. Hyperuricosuria increased with the age of the patient and when the administered dosage of pancreatic enzyme exceeded 10,000 lipase units/kg body weight. Despite normal levels of serum creatinine and urea, and normal creatinine clearance in the cystic fibrosis patients, risk of future renal damage seems obvious and preventive measures should be considered.