Early prediction of organ failure by combined markers in patients with acute pancreatitis

BACKGROUND

Several biological markers and clinical scoring systems have been used to predict the course of acute pancreatitis. Because organ failure is the most severe complication of the disease, prognostic markers and their combinations that would predict organ failure on hospital admission were sought.

METHODS

Some 351 consecutive patients with acute pancreatitis were studied. Blood samples were taken within 12 h of admission. This case-control study included all 33 patients with organ failure and 99 matched controls without organ failure. Measurements included 19 prognostic markers and Acute Physiology And Chronic Health Evaluation (APACHE) II score.

RESULTS

Plasma interleukin 10, serum glucose and serum calcium were identified as independent predictors of organ failure by logistic regression analysis. Calcium level correlated with clinical onset of organ failure. The combination of interleukin 10 (more than 50 pg/ml) or calcium (less than 1.65 mmol/l) was a significantly better predictor than any single marker or APACHE II score, with a sensitivity of 88 per cent, specificity 93 per cent and diagnostic odds ratio 94.

CONCLUSION

Organ failure in acute pancreatitis can be predicted with high accuracy at hospital admission using a combination of plasma interleukin 10 and serum calcium measurements.

Expression of COX-2 is increased with age in papillary thyroid cancer

AIMS

To study cyclooxygenase-2 (COX-2) and matrix metalloproteinase-2 (MMP-2) expression in papillary thyroid cancer (PTC). Expression of COX-2 is elevated in various human tumours and it has an important role in carcinogenesis. MMP-2 is also an important component of the metastatic potential of tumours. In PTC the most important factor affecting survival is age, but it is poorly understood why older PTC patients have a worse prognosis.

METHODS AND RESULTS

This retrospective study comprised 108 patients with PTC, and we compared patients who were either younger than 35 (n = 59) or older than 55 (n = 49). Paraffin-embedded tumour samples were analysed for COX-2 and MMP-2 protein expression using immunohistochemistry. High (scores 2-3) COX-2 immunostaining was observed in 38/108 (35%) of the tumours, and COX-2 expression was significantly (P = 0.002) higher in the older age group (25/49; 51%) than in the young one (13/59; 22%).

CONCLUSIONS

Our study shows that COX-2 expression increases with age. It is possible that the age-related increase in COX-2 expression could explain the more aggressive behaviour of PTC in the older age group compared with the young one.

Plasma anti-inflammatory cytokines and monocyte human leucocyte antigen-DR expression in patients with acute pancreatitis

BACKGROUND

Immune suppression plays a role in the pathogenesis of acute pancreatitis. The purpose was to describe plasma anti-inflammatory cytokines and blood monocyte human leucocyte antigen (HLA)-DR expression, a cellular marker of immune suppression, in relation to clinical outcome in acute pancreatitis.

METHODS

We studied 74 patients with acute pancreatitis admitted within 72 h after symptom onset; 27 had mild disease and 47 severe disease, of whom 20 developed organ failure. Plasma cytokine concentrations and monocyte HLA-DR density were determined at admission and 1, 2, 3, 7, 14 and 21 days later.

RESULTS

The levels of interleukin-1 receptor antagonist, interleukin-6 and interleukin-10 correlated inversely to monocyte HLA-DR expression; each marker correlated with disease severity. Interleukin-4, -11 and -13 levels were low. Organ failure occurred at median 36 h (range 8 to 158) after admission and was predicted at admission by the combination of interleukin-6 and interleukin-10 with sensitivity of 95%, specificity of 88% and positive likelihood ratio of 7.6 (95% confidence interval 3.3 to 17). Patients with secondary infections had a lower proportion of HLA-DR positive monocytes than did controls at day 14 (median: 32% versus 65%; n = 7) and at day 21 (median: 49% versus 83%; n = 6), P < 0.05 each. In the organ failure group, HLA-DR expression did not differ between survivors and non-survivors.

CONCLUSIONS

Determining the severity of anti-inflammatory reaction at admission and monitoring the course of immune suppression provide a means for predicting clinical outcome in acute pancreatitis.

Sequential changes in pancreatic markers in acute pancreatitis

BACKGROUND

Trypsinogen activation within acinar cells plays a crucial role in the pathogenesis of acute pancreatitis (AP). Our aim was to characterize temporal changes of trypsinogen-1, trypsinogen-2, complexes of trypsin-1-alpha1-antitrypsin (T1-AAT) and trypsin-2-alpha1-antitrypsin (T2-AAT), trypsinogen activation peptide (TAP) and pancreatic secretory trypsin inhibitor (PSTI) in patients with AP.

METHODS

The study comprised 64 consecutive patients with AP (19 with severe disease) and 32 controls. The concentrations of trypsinogen-1 and -2, PSTI, T1-AAT and T2-AAT were determined by time-resolved immunofluorometric assays (IFMA), and TAP was measured using a competitive enzyme immunoassay from serum and urine.

RESULTS

The concentrations of trypsinogen-1 and -2 in serum reflected similar patterns, but excretion of trypsinogen-1 into urine was markedly lower than that of trypsinogen-2, the concentration of which correlated strongly with disease severity. The concentrations of T1-AAT were no higher in severe AP than in mild AP, while T2-AAT concentrations were significantly higher in severe than in mild disease. PSTI increased over the course of several days, showing strong correlation with disease severity. The concentrations of plasma and urinary TAP decreased rapidly to undetectable levels. During the early phase of AP, TAP correlated with the disease severity in plasma and urine but there was no difference between controls and patients with mild AP.

CONCLUSION

More pronounced changes in trypsinogen-2 and its complex with AAT than in those of trypsinogen-1 were demonstrated, suggesting that trypsinogen-2 might play a more important role in the pathogenesis of AP than earlier believed. Urinary PSTI showed features warranting further investigations as a marker of disease severity.

Comparison of urine trypsinogen-2 test strip with serum lipase in the diagnosis of acute pancreatitis

BACKGROUND/AIMS

The accuracy of a new rapid urinary trypsinogen-2 test strip (actim Pancreatitis) was compared with that of serum lipase for detection of acute pancreatitis in patients with acute abdominal pain.

METHODOLOGY

A prospective study was conducted which consisted of 237 consecutive patients with acute abdominal pain admitted to the emergency unit at Helsinki University Central Hospital. The patients were tested on admission with the actim Pancreatitis test strip. Serum amylase, serum lipase, and urine trypsinogen-2 concentrations were also determined quantitatively.

RESULTS

The actim Pancreatitis test strip result was positive in 27 out of 29 patients with acute pancreatitis (sensitivity 93%) and in 16 of 208 patients with non-pancreatic abdominal pain (specificity 92%). This was superior to that of serum lipase (sensitivity 79% and specificity 88%). With a cut-off > 3x the upper reference limit, the sensitivity of serum lipase was only 55% while the specificity was 99%. The high sensitivity for the actim Pancreatitis test strip resulted in a very high negative predictive value of 99%. All six patients with severe acute pancreatitis were detected by the dipstick. With a higher cut-off value (> 3x upper reference limit) for lipase, two patients with severe acute pancreatitis remained undetected. Combining the actim Pancreatitis dipstick with serum lipase a positive predictive value of 94% was obtained.

CONCLUSIONS

Acute pancreatitis can be excluded with a higher probability with the actim Pancreatitis strip than with serum lipase determination, and therefore appears to be more suitable for screening of acute pancreatitis. With its high specificity with a cut-off > 3x the upper reference limit, serum lipase is suitable as a confirmatory test for pancreatitis when a positive dipstick result is obtained.

The effect of Helicobacter pylori eradication on the natural course of atrophic gastritis with dysplasia

BACKGROUND

There are few data on the natural course of Helicobacter pylori-related atrophic gastritis.

AIM

To investigate the effect of H. pylori eradication on advanced atrophic gastritis in the corpus.

METHODS

Twenty-two elderly men with H. pylori infection and moderate or severe atrophic corpus gastritis formed the study population. These men were under endoscopic surveillance because of the presence of indefinite or definite dysplastic gastric lesions in addition to atrophic corpus gastritis. The men were gastroscopically and bioptically examined four times before they received H. pylori eradication therapy (mean follow-up time, 7.5 years), and once again 2.5 years after eradication therapy. Serum levels of pepsinogen I and H. pylori antibodies were analysed at baseline, immediately before and 2.5 years after eradication therapy.

RESULTS

During the 7.5-year period prior to eradication therapy, no significant changes were observed in the mean atrophy and intestinal metaplasia scores or in the mean serum level of pepsinogen I. However, a significant improvement occurred in the mean histological scores of inflammation (from 2.2 to 0.5), atrophy (from 2.2 to 1.2) and intestinal metaplasia (from 1.6 to 1.1) in the corpus mucosa after H. pylori eradication. In addition, the mean serum level of pepsinogen I increased from 16.3 to 25.7 microg/L (P=0.0071, Wilcoxon signed rank test) after eradication therapy.

CONCLUSIONS

The results suggest that advanced atrophic corpus gastritis (and intestinal metaplasia) improves and may even heal after the eradication of H. pylori.

Predicting the severity of acute pancreatitis by rapid measurement of trypsinogen-2 in urine

BACKGROUND

Early identification of patients at risk of developing a severe attack of acute pancreatitis (AP) is of great importance because rapid therapeutic interventions improve outcome. At a cutoff of 50 microg/L, trypsinogen-2 measured by a rapid urinary dipstick is a sensitive and specific diagnostic test in AP. The trypsinogen-2 concentration correlates with the severity of the disease, and a test with a higher cutoff might therefore be useful for prediction of disease severity.

METHODS

We increased the detection limit of the urinary trypsinogen-2 test strip (Actim Pancreatitis) from 50 microg/L to 2000 microg/L and evaluated the prognostic value of this test. The results were compared with those obtained with serum C-reactive protein and the acute physiology and chronic health evaluation II (APACHE II) score. The study population consisted of 150 consecutive patients with AP (42 with severe disease).

RESULTS

The sensitivity of the rapid urinary test strip (detection limit, 2000 microg/L) for prediction of severe AP, both on admission and at 24 h, was 62%; specificities were 87% and 85%, respectively, positive predictive values were 65% and 62%, and negative predictive values were 85% and 85%. C-Reactive protein had a sensitivity of only 38% on admission, but at 24 h, it was 83%; specificities were 90% and 70%, respectively, whereas positive predictive values were 59% and 52%, and NPVs were 79% and 91%, respectively. On admission the positive-likelihood ratio for the urinary trypsinogen-2 test strip was 4.8, and at 24 h it was 4.2; for C-reactive protein, the values were 3.7 and 2.7, respectively.

CONCLUSIONS

The urinary trypsinogen-2 dipstick is a simple and rapid method for prediction of severe acute pancreatitis.

Cellular markers of systemic inflammation and immune suppression in patients with organ failure due to severe acute pancreatitis

BACKGROUND

Few data are available on cellular markers of systemic inflammation and immune suppression in early acute pancreatitis. The aim of this study was to describe the cellular immune inflammatory status of patients with acute pancreatitis in relation to development of organ failure.

METHODS

Prospective study including 89 patients who presented within 72 h of onset of pain. Fifty-eight of them had mild disease (Grade I group), 19 had severe disease with no organ dysfunction (Grade II group) and 12 had severe disease with organ dysfunction (Grade III group). Serial blood samples were collected on admission and following 2 days. Phagocyte surface markers were analysed using flow cytometry.

RESULTS

The proportion of HLA-DR-positive monocytes, a marker of immune suppression, and CD11b expression level on neutrophils and monocytes, a marker of systemic inflammation, were related to Grades I-III (P for trend <0.001). In Grade III patients, the proportion of HLA-DR-positive monocytes was low on presentation, or decreased rapidly during follow-up, whereas CD11b expression levels were persistently high. L-selectin and monocyte CD14 expression levels were not related to disease severity.

CONCLUSIONS

Immune suppression develops early, rapidly and unexpectedly in patients with acute pancreatitis. Monitoring immune inflammatory status may provide the means by which to identify patients who benefit from biological response modifier therapy.

Procalcitonin strip test in the early detection of severe acute pancreatitis

BACKGROUND

Early identification of patients who subsequently develop severe acute pancreatitis would enable the selection of patients who may benefit from early intensive management. Because severe acute pancreatitis is characterized by the development of systemic inflammation the authors studied whether procalcitonin, a marker of systemic inflammation, differentiated between patients with mild and severe acute pancreatitis.

METHODS

On admission and 24 h thereafter, serum procalcitonin level was measured by a rapid, semiquantitative PCT-Q test and serum C-reactive protein (CRP) by an immunoturbidimetric method in a consecutive series of 162 patients with acute pancreatitis. There were 38 severe and 124 mild cases. The accuracy of procalcitonin and CRP in predicting severe acute pancreatitis was compared with that of Ranson and Acute Physiology and Chronic Health Evaluation (APACHE) II scores.

RESULTS

The PCT-Q test was more accurate in predicting severe acute pancreatitis (sensitivity 92 per cent and specificity 84 per cent at 24 h) than CRP, APACHE II score and Ranson score. Its negative predictive value was high (97 per cent at 24 h), and it detected each patient who developed subsequent organ failure (n = 22).

CONCLUSION

The PCT-Q test was a useful screening method for detecting severe acute pancreatitis. It is simple and quick to perform and, unlike currently available multiple factor scoring systems, can easily be adopted into routine clinical practice.

An institutional experience with 40 first lateral transperitoneal laparoscopic adrenalectomies

Laparoscopic adrenalectomy is gaining widespread acceptance. To evaluate this new approach, the authors evaluated 40 laparoscopic adrenalectomies. Between June 1995 and February 1999, 40 lateral transperitoneal laparoscopic adrenalectomies were performed in 38 patients. The clinical diagnoses were primary aldosteronism (20 patients), Cushing adenoma (2 patients), cortical hyperplasia with hypercortisolism (2 patients), pheochromocytoma (8 patients), and other conditions (6 patients). There were no deaths or subsequent procedures. The mean operative time was 121 minutes. One procedure performed for hypercortisolism was converted to open adrenalectomy because of hepatomegaly and postoperative adhesions. Seven patients had complications: one patient with small pulmonary embolus with transient dyspnea, one patient with pneumothorax, two patients with postoperative bleeding, two patients with prolonged pain at a trocar wound, and one patient with a urinary tract infection. Lateral transperitoneal laparoscopic adrenalectomy seems to be a safe and effective minimally invasive approach for adrenal surgery, and the authors consider it to be the standard surgical procedure for benign adrenal tumors.

Time course profile of serum trypsinogen-2 and trypsin-2-alpha1-antitrypsin in patients with acute pancreatitis

BACKGROUND

Trypsinogen-2 and the trypsin-2-alpha1-antitrypsin complex are recently introduced new laboratory markers for acute pancreatitis. They show high sensitivity and specificity for acute pancreatitis on admission, but little is known on their time course profiles.

METHODS

The serum concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin were monitored in 92 patients with verified acute pancreatitis. The follow-up period was 42 days in patients with severe acute pancreatitis (N = 73) and 9 days in mild disease (N = 19).

RESULTS

On admission the mean serum concentration of trypsinogen-2 was 2880 microg/l in severe and 920 microg/l in mild acute pancreatitis. These values were 32- and 10-fold the upper reference limit, respectively. Trypsin-2-alpha1-antitrypsin concentrations were 1250 microg/l (100-fold the upper reference limit) and 635 microg/l (52-fold), respectively. The differences were statistically significant (P = 0.026-0.001). The concentrations of trypsinogen-2 and trypsin-2-alpha1-antitrypsin decreased gradually during the follow-up period, but they remained elevated for the entire study period in patients with severe and mild disease.

CONCLUSIONS

The time course profile of trypsinogen-2 and trypsin-2-alpha1-antitrypsin is favorable for diagnosing acute pancreatitis. The elevation starts within hours after the onset of the disease and it is very steep. Both markers remain elevated longer than amylase and the magnitude of the elevation correlates with the severity of the disease. This is further evidence to support the use of trypsinogen-2 and trypsin-2-alpha1-antitrypsin for the evaluation of patients suspected of having acute pancreatitis.

Natural course of adrenal incidentalomas: seven-year follow-up study

Most adrenal incidentalomas are nonfunctioning cortical adenomas that do not require surgery. Operative treatment is indicated if the incidentaloma has malignant features as seen during the radiologic workup, is hormonally active, or grows during follow-up. A conservative attitude is justified in asymptomatic patients if we know that the natural course of these tumors is not disadvantageous. We followed a group of patients treated by observation to determine the natural course of adrenal incidentalomas. Altogether 30 incidentalomas in 27 patients were detected in the Helsinki University Central Hospital from June 1981 through December 1992 and were re-examined during 1997. The patients were evaluated clinically, and hormonal testing was done by performing a 1-mg overnight dexamethasone suppression test; the next day we measured the 24-hour urinary excretion of vanillylmandelic acid, metanephrines and normetanephrines, and serum potassium. Magnetic resonance imaging (MRI) was used to determine the size of the tumor. If the patient had died during the follow-up period, the causes of death from the death certificates and autopsy reports were reviewed. The mean follow-up was 7 years. Nine patients had died, with none of deaths related to the incidentaloma. Sixteen patients were evaluated clinically and by the basic hormonal tests and MRI; none showed any signs of hormonal activity or features of malignancy. Two patients did not want to be reexamined but stated that they were asymptomatic. This follow-up study supports the conclusion that conservative therapy is justified because the growth tendency of adrenal incidentalomas is slow and they seem to remain hormonally inactive.

Diagnosis of Helicobacter pylori infection in patients with atrophic gastritis: comparison of histology, 13C-urea breath test, and serology

BACKGROUND

Atrophic gastritis, a risk factor for gastric cancer, is a late consequence of Helicobacter pylori infection in approximately one-third of the infected patients. It has been suggested that gastric cancer would develop less frequently if H. pylori were eradicated. However, the prevalence of H. pylori infection may be underestimated in patients with atrophic gastritis and intestinal metaplasia if only biopsy-based diagnostic methods are used.

METHODS

We compared histology, 13C-urea breath test (13C-UBT), and serology in H. pylori diagnostics in 50 male patients with atrophic corpus gastritis.

RESULTS

H. pylori was detected in 15 (30%) patients by histology and in 14 (28%) by 13C-UBT, whereas increased serum antibody levels indicating H. pylori infection were found in 41 (82%) patients (P < 0.0001 between serology and both histology and 13C-UBT). H. pylori infection was associated with atrophic corpus gastritis in 84% of the present patients (in one patient with normal antibody titres H. pylori was defined histologically).

CONCLUSIONS

H. pylori infection would have been missed in most patients with atrophic gastritis without the analysis of H. pylori antibodies. Therefore, in patients with atrophic gastritis, the use of serology is encouraged in diagnosing H. pylori infection.

Reliable screening for acute pancreatitis with rapid urine trypsinogen-2 test strip

BACKGROUND

This study was designed to evaluate the validity of a new rapid urinary trypsinogen-2 test strip (Actim Pancreatitis) for detection of acute pancreatitis in patients with acute abdominal pain.

METHODS

A total of 525 consecutive patients presenting with abdominal pain at two emergency units was included prospectively and tested with the Actim Pancreatitis test strip. Urine trypsinogen-2 concentrations were also determined by a quantitative method. The diagnosis and assessment of severity of acute pancreatitis was based on raised serum and urinary amylase levels, clinical features and findings on dynamic contrast-enhanced computed tomography.

RESULTS

In 45 patients the diagnosis of acute pancreatitis could be established. The Actim Pancreatitis test strip result was positive in 43 of them resulting in a sensitivity of 96 per cent. Thirty-seven false-positive Actim Pancreatitis test strips were obtained in patients with non-pancreatic abdominal pain resulting in a specificity of 92 per cent. Nine patients with severe acute pancreatitis were all detected by the dipstick.

CONCLUSION

A negative Actim Pancreatitis strip result excludes acute pancreatitis with high probability. Positive results indicate the need for further evaluation, i.e. other enzyme measurements and/or radiological examinations. The test is easy and rapid to perform, unequivocal in its interpretation and can be used in healthcare units lacking laboratory facilities.

Extracellular phospholipases A2 in relation to systemic inflammatory response syndrome (SIRS) and systemic complications in severe acute pancreatitis

The pathophysiology of severe acute pancreatitis (AP) resembles other conditions with systemic inflammatory response syndrome (SIRS) such as sepsis predisposing to remote organ failure. Because extracellular phospholipases A2 (PLA2) have been implicated in AP, their serum concentrations were analyzed with respect to SIRS and systemic complications in patients with severe AP. The serum samples were collected daily for 12 days in 57 patients with severe AP. SIRS, early organ complications, local complications, and outcome of AP were recorded. Time-resolved fluoroimmunoassays were used for group I and group II PLA2 measurements. Thirty-nine (68.4%) patients fulfilled the criteria of SIRS within 12 days from admission. Pancreatic necrosis was detected in 43 (75.4%) patients. Infected necrosis was found preoperatively or at operation in five (8.8%) patients. Twenty-six (45.6%) and eight (14.0%) patients had respiratory or renal failure, respectively. Seven (12.3%) patients died of their disease. All patients with systemic complications fulfilled the criteria of SIRS. The increasing number of positive SIRS criteria was associated with increased frequency of systemic complications. Pancreatic necrosis was not significantly associated with SIRS. The serum concentration of group II PLA2 was significantly higher in patients with SIRS (p < 0.05) compared with patients without from day 7 onward. The concentration of group II PLA2 increased (p < 0.01) in patients with SIRS but decreased in patients without. The serum concentration of group II PLA2 did not differ significantly with respect to systemic complications. The concentration of group I PLA2 decreased (p < 0.05) similarly in patients with and without SIRS or systemic complications during follow-up, respectively. Early systemic complications of severe AP are associated with SIRS with increasing frequency as the number of positive SIRS criteria increases. Group II PLA2 but not group I PLA2 may have pathophysiologic importance in severe AP-associated SIRS. Increasing serum concentration of group II PLA2 seems to reflect the ongoing systemic inflammation in severe AP-associated SIRS.

The value of ultrasound-guided fine-needle aspiration biopsy (FNAB) and frozen section examination (FS) in the diagnosis of thyroid cancer

BACKGROUND AND AIMS

Although only a small minority of thyroid nodules are malignant, a large proportion of operations are performed to exclude malignancy. The purpose of this study was to evaluate the role of preoperative ultrasound-guided fine-needle aspiration biopsy (FNAB) and intraoperative frozen section examination (FS) in the management of thyroid cancer.

MATERIAL AND METHODS

A retrospective study of 664 consecutive patients operated on for thyroid cancer from 1966 through 1994 at the Meilahti Hospital was performed. FNAB was taken with manual guidance in the sixties and seventies and with ultrasound guidance in the eighties and nineties. FS was performed in 335 cases. Malignancy was not known preoperatively in 210 cases.

RESULTS

Ultrasound-guided FNAB was more accurate than manually guided FNAB (75 out of 143 or 52.4% vs. 112 out of 276 or 40.6%) in detecting malignancy in spite of the fact that the tumors were smaller (23 +/- 15 mm vs. 30 +/- 22 mm, p = 0.011). A true positive FS diagnosis was given in 250 out of 335 (74.6%) of patients. However, in follicular carcinoma, the amount of true positive FS diagnoses was only 12 out of 27 (44.4%).

CONCLUSIONS

Ultrasound guidance has improved the sensitivity of FNAB. Follicular neoplasia is a problem for both FNAB and FS.

Bactericidal/permeability-increasing protein and group I and II phospholipase A2 during the induction phase of human acute pancreatitis

Activated endogenous mediators of inflammation have important roles in the pathogenesis and complications of acute pancreatitis (AP). These mediators include bactericidal/ permeability-increasing protein (BPI) and phospholipase A2 (PLA2). The time course of their activation during human AP is not known. The aim of this study was to evaluate the kinetics of BPI, group I (pancreatic) and group II (synovial type) PLA2 during human AP with temporally defined onset, as being induced by endoscopic retrograde cholangiopancreatography (ERCP). Serum samples of 273 consecutive patients undergoing ERCP were collected before and at 3, 6, and 24 h after ERCP. Twenty-four (8.7%) patients developed ERCP-induced pancreatitis. Seven of them were graded to have a severe disease. Forty randomly selected patients undergoing ERCP without evidence of pancreatitis served as controls. The serum concentrations of BPI and groups I and II PLA2 were measured by specific immunoassays. The mean concentration of BPI increased from 14 to 26 microg/L at 24 h after ERCP in patients with AP. In the control group, BPI values remained unchanged, and the difference was statistically significant (p<0.001). The increase of BPI was seen in 22 of 28 patients with AP at 3 h after the onset of the disease. BPI values were higher in severe post-ERCP pancreatitis than in mild disease (p = 0.07; NS). The serum concentrations of group II PLA2 before ERCP were consistently higher in the control patients than in the patients with pancreatitis, 65.8 and 14.2 microg/L, respectively. High baseline values in the control group were associated with preexisting infectious diseases. Thereafter, the mean concentration decreased in the control group to 44 microg/L and increased in the pancreatitis group up to 27.5 microg/L. The difference was statistically significant (p = 0.007). Increased group II PLA2 values were seen in 10 of 17 patients with mild AP and in five of seven patients with severe disease. There were no significant differences in group I or II PLA2 values in patients with mild or severe AP. The serum concentration of group I PLA2 increased in the patients with post-ERCP pancreatitis from 5.4 to 37.5 microg/L at 24 h. The difference was statistically significant, (p< 0.001) as compared with controls. In conclusion, in acute pancreatitis, the increase of BPI in serum starts at 3 h after the onset of the disease, and the concentration seems to correlate with the severity of the disease. Increased group II PLA2 concentrations also were seen in patients with mild AP. The kinetics of group I PLA2 resembles that of other pancreatic enzymes.

Laparoscopic adrenalectomy for primary aldosteronism: clinical experience in 12 patients

Laparoscopic adrenalectomy has become a viable option for removal of small adrenal neoplasms. We present our initial experience of this operation for primary aldosteronism. In this prospective study, 12 consecutive patients with primary aldosteronism were operated on laparoscopically by one surgeon. Operative time, blood loss, postoperative pain, complications, hospital stay, convalescence time, and outcome were analyzed. Five right-sided and seven left-sided adrenalectomies were performed in six female and six male patients with a mean age of 51 years. The mean operative time was 126 minutes. All procedures were successfully carried out laparoscopically. No major complications occurred. All patients turned normokalemic and the medication for hypertension could be stopped or diminished in all cases. The mean hospital stay was 3.4 days, and the mean sick leave was 13 days. Laparoscopic adrenalectomy seems to be a safe and effective treatment for primary aldosteronism and should be considered the operation of choice.

Evaluation of a new urinary amylase test strip in the diagnosis of acute pancreatitis

We have developed a novel rapid test strip for detecting pancreatic amylase in urine and prospectively evaluated its accuracy in screening for acute pancreatitis (AP). The test strip is based on the immunochromatography principle and uses two monoclonal antibodies specific for pancreatic amylase. Urine samples were collected from 500 consecutive patients with acute abdominal disease (52 with AP) and prospectively tested with the strip. The accuracy of the test strip was compared with that of two quantitative urine amylase determinations and a urinary dipstick test for amylase (Rapignost). Sensitivity of the test was 69% and specificity was 97% in differentiating patients with AP from those with acute abdominal extrapancreatic disease at admission. The negative predictive value was 0.986. The test showed moderate agreement both with an assay measuring total amylase activity and with another measuring pancreatic amylase immunoreactivity. At similar high specificity (97%), quantitative determination of total amylase activity (cut-off 3960 U/L) and pancreatic amylase (cut-off 2180 micrograms/L) showed lower sensitivity (54% and 41%) than the test strip (69%). The test is specific and rapid to perform, and it rules out AP with high probability. It could therefore be useful in an emergency setting without laboratory facilities in the differential diagnosis of acute abdominal pain.

Diagnosis of acute pancreatitis

There is no golden standard for the diagnosis of acute pancreatitis (AP). The diagnosis is currently based on clinical presentation, measurement of released pancreatic enzymes and imaging studies. Serum/urinary amylase, lipase and trypsinogen-2 dipstick are the most applicable methods in the clinical practice largely because of their simple, rapid, inexpensive and readily available assay methods. In addition to the clinical picture, inflammatory markers (CRP) or contrast enhanced CT can be used to assess the severity of acute pancreatitis. Multifactorial scoring systems (Ranson's prognostic signs, APACHE II, MOF-score) may be too cumbersome for clinical practice. Patient history, determination of AST, bilirubin and alkaline phosphatase levels as well as imaging studies such as ultrasonography and ERCP can be used to distinguish between biliary and non-biliary origin of the disease.

Current principles of treatment in acute pancreatitis

The treatment of mild acute pancreatitis (AP) with fluid replacement and other conservative measures is adequate and sufficient in the majority of patients. The corner-stones of the treatment of patients with severe acute pancreatitis include early aggressive fluid resuscitation, intensive care with close monitoring and support of organ function, antibiotic prophylaxis, early supportive treatment of organ failure, and surgery in selected cases with infected pancreatic necrosis or deterioration of patient's condition in spite of maximal conservative therapy. Early endoscopic removal of common bile duct stones should be considered in cases with biliary AP. Altogether, increased accuracy in early diagnosis and development of intensive care have resulted in a significant decrease in mortality of patients with severe pancreatitis. In this paper, we review the current principles and methods of treatment in acute pancreatitis at Helsinki University Central Hospital.

Presence of high-level DNA copy number gains in gastric carcinoma and severely dysplastic adenomas but not in moderately dysplastic adenomas

Our aim was to investigate the presence of DNA copy number changes in gastric adenomas and to identify the changes that may play a role in gastric carcinogenesis. DNA copy number changes in 16 patients with gastric adenoma and in 22 tumors from patients with intestinal type gastric carcinomas were studied by using comparative genomic hybridization. DNA copy number changes were found in 44% of the adenoma cases and in 86% of the intestinal type gastric carcinomas. On average, gains were more common than losses (0.9 vs. 0.5 in adenomas and 4.1 vs. 1.8 in carcinomas). In adenomas, the most common gains involved chromosome 8 in 3 cases, and gain of chromosome 7 and 20q was detected in 2 cases. The most frequent losses were observed at 5q (three times). Only adenomas with severe dysplasia showed high-level amplifications that were detected at chromosome 13, 17cen-q22, and 20q12-ter. In gastric cancer, the most common gains were detected at 20q (55%), 17q12-q21 (41%), and 8q (41%), and the most common losses were detected at 18q (41%) and 4q (32%). High-level amplifications were observed at 20q (3 tumors), 17cen-q21 (3 tumors), 2p (1 tumor), and 18q (1 tumor). These findings suggest that the progression of dysplasia is associated with higher levels of DNA copy number increase (e.g., the gains at 17q and 20q), which were typically observed in the intestinal type gastric cancer. Furthermore, the results support the hypothesis that adenoma precedes cancer.

Positive result by serology indicates active Helicobacter pylori infection in patients with atrophic gastritis

Patients with atrophic corpus gastritis and elevated Helicobacter pylori antibody titers but 13C-urea breath test (13C-UBT) and histology results negative for H. pylori were randomized into eradication therapy or follow-up only. Antibody levels decreased significantly in six out of seven patients in the eradication group, while in the follow-up group, the titers declined in only one out of eight patients. In patients with atrophic corpus gastritis, positive serology results may indicate an ongoing infection in spite of negative 13C-UBT and histology results.

Adrenalectomy for primary aldosteronism: long-term follow-up study in 29 patients

Primary aldosteronism consists of a mixture of subgroups. The operative treatment is successful only in cases of aldosterone-producing neoplasia (and in rare cases of primary unilateral hyperplasia); all other cases should be treated medically. The aim of this study was to determine if aldosterone-producing neoplasia had been successfully differentiated from the other subgroups and the outcome of operative treatment. Altogether 29 patients with primary aldosteronism were operated on between January 1, 1979 and December 31, 1993. Patient charts were reviewed retrospectively. The follow-up data were collected from the patients' charts, and all patients were contacted to obtain recent blood pressure and serum potassium values. The patients were asked about symptoms related to hyperaldosteronism. If any suspicion of recidive aldosteronism was present, patients were carefully reexamined by hormonal tests and computed tomography (CT). A total of 27 patients had unilateral adenoma, 1 patient had hyperplasia, and 1 patient had an aldosterone-producing cortical carcinoma. There was no operative mortality or morbidity. The serum potassium level had normalized in all patients. Mean follow-up time was 76 months. One patient died during the follow-up from cholangiocarcinoma; 11 patients (41%) were cured by the operation, 10 patients (37%) have a mild but medicated hypertension, and in the remaining 22% the hypertension persisted but was well controlled by the medication. Of the 29 patients, 28 were correctly diagnosed as having an aldosterone-producing neoplasm. Basic hormonal studies and CT can be used effectively to differentiate aldosterone-producing neoplasia from hyperplasia in most cases.

The risk of gastric carcinoma and carcinoid tumours in patients with pernicious anaemia. A prospective follow-up study

BACKGROUND

This endoscopic follow-up study was undertaken to evaluate the risk of gastric cancer (GC) and carcinoids in patients with pernicious anaemia (PA) and to analyse whether early detection of GC could be provided by regular endoscopic follow-up.

METHODS

Screening gastroscopy was performed in 71 patients with pernicious anaemia, and thereafter they were followed up with gastroscopies at 3-year intervals for a mean time of 5.8 years. Standardized incidence ratios (SIR) were calculated, the expected number being based on incidence rates in the whole Finnish population.

RESULTS

Two GCs were found during the follow-up period; one of these patients was asymptomatic and the other had abdominal symptoms. The SIR was 5.0 (95% confidence interval, 0.6-18). Eight carcinoids were detected, and all but one were removed endoscopically, and no metastases were found. The patients who had carcinoid tumours were younger at the diagnosis of PA than those who did not develop carcinoids (mean, 40 versus 55 years). Additionally, the patients with carcinoids had longer duration of PA (mean, 11 versus 5 years).

CONCLUSIONS

During the follow-up period the risk of GC was increased. The risk of gastric carcinoids seems to be very high in patients with pernicious anaemia when compared with a normal population, but they are mostly relatively benign tumours. Regular routine gastroscopic follow-up is not indicated in patients with pernicious anaemia.

Increased serum trypsinogen 2 and trypsin 2-alpha 1 antitrypsin complex values identify endoscopic retrograde cholangiopancreatography induced pancreatitis with high accuracy

AIMS

To evaluate the clinical utility of two new tests for serum trypsinogen 2 and trypsin 2-alpha 1 antitrypsin complex (trypsin 2-AAT) in diagnosing and assessing the severity of acute pancreatitis (AP) induced by endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS

Three hundred and eight consecutive patients undergoing ERCP at Helsinki University Central Hospital in 1994 and 1995.

METHODS

Patients were followed prospectively for pancreatitis and clinical outcome. They were tested for serum trypsinogen 2, trypsin 2-AAT, and amylase in samples obtained before and one, six, and 24 hours after ERCP.

RESULTS

Pancreatitis developed in 31 patients (10%). Their median serum trypsinogen 2 increased 26-fold to 1401 micrograms/l at six hours after the procedure and trypsin 2-AAT showed an 11-fold increase to 88 micrograms/l at 24 hours. The increase in both markers was stronger in severe than in mild pancreatitis, and in patients without pancreatitis there was no significant increase. Baseline trypsinogen 2 and trypsin 2-AAT concentrations were elevated in 29% and 32% of patients, respectively. The diagnostic accuracy of a threefold elevation over the baseline value was therefore analysed. The sensitivity and specificity of these parameters in the diagnosis of post-ERCP pancreatitis was 93% and 91%, respectively, for serum trypsinogen 2 at six hours after the examination, and 93% and 90%, for trypsin 2-AAT at 24 hours.

CONCLUSIONS

Serum trypsinogen 2 and trypsin 2-AAT reflect pancreatic injury after ERCP. High concentrations are associated with severe pancreatic damage. The delayed increase in trypsin 2-AAT compared with trypsinogen 2 appears to reflect the pathophysiology of AP. A greater than threefold increase in trypsinogen 2 six hours after ERCP is an accurate indicator of pancreatitis.

17q12-21 amplicon, a novel recurrent genetic change in intestinal type of gastric carcinoma: a comparative genomic hybridization study

We studied DNA copy number changes in gastric cancer (GC) using comparative genomic hybridization (CGH) analysis on 35 resected gastric carcinomas (22 of the intestinal type and 13 of the diffuse type). Eighty-three percent of the cases showed DNA copy number changes. Gains were more common than losses (median of 3 and 1 in primary tumors of the intestinal and diffuse type, respectively). The most common gains were detected on 20q [46%; 12 intestinal type (55%) and four diffuse type (31%)], 8q [37%; 10 intestinal type (45%) and three diffuse type (23%)], and 17q12-21 [29%; all but one intestinal type (41%)]. The most frequent losses were detected on 18q [26%; all intestinal type (41%)] and on 4q [23%; all intestinal type (32%)]. High-level amplifications were observed in the intestinal type of tumors at 17q12-21 (three tumors), 20q (three tumors). 2q (one tumor), and 18q (one tumor). In the diffuse type, high-level amplification was detected once at 13q.

17q12-21 amplicon, a novel recurrent genetic change in intestinal type of gastric carcinoma: a comparative genomic hybridization study

We studied DNA copy number changes in gastric cancer (GC) using comparative genomic hybridization (CGH) analysis on 35 resected gastric carcinomas (22 of the intestinal type and 13 of the diffuse type). Eighty-three percent of the cases showed DNA copy number changes. Gains were more common than losses (median of 3 and 1 in primary tumors of the intestinal and diffuse type, respectively). The most common gains were detected on 20q [46%; 12 intestinal type (55%) and four diffuse type (31%)], 8q [37%; 10 intestinal type (45%) and three diffuse type (23%)], and 17q12-21 [29%; all but one intestinal type (41%)]. The most frequent losses were detected on 18q [26%; all intestinal type (41%)] and on 4q [23%; all intestinal type (32%)]. High-level amplifications were observed in the intestinal type of tumors at 17q12-21 (three tumors), 20q (three tumors). 2q (one tumor), and 18q (one tumor). In the diffuse type, high-level amplification was detected once at 13q.

Urinary trypsinogen-2 test strip in detecting ERCP-induced pancreatitis

BACKGROUND AND STUDY AIMS

We have evaluated a new urinary trypsinogen-2 test strip, based on the principle of immunochromatography, in the diagnosis of acute pancreatitis induced by endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

One hundred six consecutive patients undergoing ERCP (with opacification of the pancreatic duct) at the Helsinki University Central Hospital were included in the study. Patients were tested with a urinary trypsinogen-2 test strip six hours after ERCP. Quantitative trypsinogen-2 as well as serum and urine amylase values were measured before the procedure and six hours after it.

RESULTS

In patients developing pancreatitis after ERCP, the median urinary trypsinogen-2 concentration six hours after the endoscopic procedure was 1780 micrograms/l (range 29-10,700 micrograms/l), and in patients without pancreatitis the median concentration was 3.6 micrograms/l (range 0.1-3390 micrograms/l; P < 0.0001). The sensitivity and specificity figures for the urinary trypsinogen-2 test strip results in diagnosing post-ERCP pancreatitis were comparable (81% and 97%, respectively) to those for serum amylase (91% and 96%) and urine amylase measurements (81% and 95%). The test strip showed a good correlation (kappa = 0.75) with the quantitative trypsinogen-2 assay.

CONCLUSIONS

The increase in urinary trypsinogen-2 concentration after ERCP reflects pancreatic injury, and can be detected by the test strip. Patients should be tested before the ERCP procedure as well, since elevated baseline values occur. The test is reliable and easy to perform even on an outpatient basis. However, its clinical usefulness requires evaluation in further trials.

MRI and CT in blunt renal trauma: an update

In our experience, MRI is as effective as CT in correctly staging renal injury. The coronal and sagittal slice orientations of MRI are particularly helpful in determining the extent of the renal parenchymal damage. Both methods are accurate in finding perirenal hematomas, assessing the viability of renal fragments, and detecting preexisting renal abnormalities but are relatively inaccurate in visualizing urinary extravasation. Although CT remains the method of choice in radiological staging of renal injury, MRI can complement CT in patients with severe renal injury, preexisting renal abnormality, equivocal CT findings, or when repeated radiological follow-up is required. MRI could replace CT in patients with iodine allergy and be used for initial staging if CT is not available.

Risk of gastric carcinoma in patients with mucosal dysplasia associated with atrophic gastritis: a follow up study

AIMS

To assess the risk of gastric carcinoma in patients with histologically verified dysplasia and atrophic gastritis of the stomach.

METHODS

One hundred and one patients with mild (n = 84), moderate (n = 14), or severe (n = 3) dysplasia among 359 elderly men who smoked underwent gastroscopy because of low serum pepsinogen. Patients with dysplasia were prospectively followed up for an average of four years with repeated gastroscopies and multiple biopsies.

RESULTS

Four of the 84 (4.8%) cases of mild dysplasia had progressed to moderate dysplasia during the follow up. Most of the cases of mild dysplasia had resolved spontaneously. No surgical intervention was required. Three of the 14 (21%) cases of moderate dysplasia had progressed to severe dysplasia, but no carcinomas were observed during follow up. Five moderately dysplastic lesions were removed surgically or endoscopically. In two of these five cases, moderate or severe dysplasia recurred. Two of the three severe dysplasias progressed to carcinoma.

CONCLUSIONS

In atrophic gastritis progression of mild and moderate dysplastic lesions seems to be a slow process and is rare in mild dysplasia. However, severe dysplasia is highly predictive of subsequent cancer. It is suggested that a five year follow up interval is sufficient in cases with mild dysplasia and two years in those with moderate dysplasia. Local removal of moderate dysplasia is indicated but does not guarantee that the lesion will not progress. Severe dysplasia requires immediate surgical intervention.

Pancreatitis associated protein as an early marker of acute pancreatitis

BACKGROUND

Measuring serum pancreatitis associated protein (PAP) in acute pancreatitis has proved valuable to monitoring the course of the disease and the recovery of the patient.

AIMS

The aim was to analyze the utility of PAP on admission as a diagnostic and prognostic marker of acute pancreatitis.

PATIENTS

Values of PAP were prospectively analyzed in 80 healthy volunteers, 164 patients with abdominal pain but without pancreatitis, 109 patients with mild acute pancreatitis, and 38 patients with severe acute pancreatitis.

METHODS

The diagnosis of acute pancreatitis was verified with clinical, laboratory, radiological, and in some cases findings at operation or necropsy.

RESULTS

Mean (95% confidence intervals) serum PAP values were 27 (24 to 29) micrograms/l in healthy volunteers, 78 (59 to 96) micrograms/l in patients with abdominal pain, 191 (134 to 247) micrograms/l, in patients with mild acute pancreatitis, and 599 (284 to 914) micrograms/l in patients with severe acute pancreatitis. Differences between the groups were significant (p = 0.04 - 0.01). Despite the differences in means, the ranges overlapped between the groups. The sensitivity of PAP on admission to detect acute pancreatitis was 38%-53% and the respective specificity 89%-77% depending on the cut off level. The sensitivity of PAP to detect severe acute pancreatitis was 45%-68% and the specificity 74%-59% depending on the cut off level.

CONCLUSIONS

Admission PAP did not distinguish severe from mild acute pancreatitis better than C reactive protein. Measurement of PAP does not give appreciable diagnostic advantages in the early phase of acute pancreatitis.

Serum complex of trypsin 2 and alpha 1 antitrypsin as diagnostic and prognostic marker of acute pancreatitis: clinical study in consecutive patients

OBJECTIVE

To estimate the usefulness of serum concentrations of the complex of trypsin 2 and alpha 1 antitrypsin in diagnosing and assessing the severity of acute pancreatitis in comparison with serum C reactive protein, amylase, and trypsinogen 2 concentrations (reference markers).

DESIGN

Markers were measured in consecutive patients admitted with acute abdominal pain that was either due to pancreatitis or to other disease unrelated to the pancreas (controls).

SETTING

Department of surgery of a teaching hospital in Helsinki.

SUBJECTS

110 patients with acute pancreatitis and 66 with acute abdominal diseases of extrapancreatic origin. On the basis of the clinical course, acute pancreatitis was classified as mild (82 patients) or severe (28 patients).

MAIN OUTCOME MEASURES

Clinical diagnosis of acute pancreatitis and severity of the disease.

RESULTS

At admission all patients with acute pancreatitis had clearly raised concentrations of trypsin 2-alpha 1 antitrypsin complex (32 micrograms/l), whereas only three of the controls had such values. Of the markers studied, trypsin 2-alpha 1 antitrypsin complex had the largest area under the receiver operating curve, both in differentiating acute pancreatitis from extrapancreatic disease and in differentiating mild from severe disease.

CONCLUSIONS

Of the markers studied, trypsin 2-alpha 1 antitrypsin complex was the most accurate in differentiating between acute pancreatitis and extrapancreatic disease and in predicting a severe course for acute pancreatitis.

Serum trypsinogen-2 in the prediction of outcome in acute necrotizing pancreatitis

BACKGROUND

The accuracy of serum trypsinogen-2 in predicting the severity of acute necrotizing pancreatitis (ANP) was prospectively evaluated in 52 consecutive patients.

METHODS

A new sensitive immunofluorometric assay was used for serum trypsinogen-2,

RESULTS

Mean values during the first 24 h were 42.1 micrograms/l in control patients, 1435 micrograms/l in uncomplicated cases, and 4090 micrograms/l in complicated or fatal cases. There was a significant difference in serum trypsinogen-2 values between patients with uncomplicated and complicated disease (p = 0.002) already on admission. When a cutoff level of 1000 micrograms/l was used, patients with uncomplicated ANP were differentiated from patients with complicated ANP with a sensitivity of 91% and with a specificity of 71%.

CONCLUSIONS

The immunofluorometric assay of serum trypsinogen-2 is a sensitive and specific method for prediction of the severity of the disease in necrotizing pancreatitis.

Helicobacter pylori infection in young patients with gastric carcinoma

BACKGROUND

Helicobacter pylori infection has been linked with chronic atrophic gastritis and gastric cancer. This case-control study was performed to investigate a possible relationship between H. pylori infection and gastric cancer in young age groups.

METHODS

Gastrectomy and/or biopsy samples were collected from 50 consecutive patients 45 years old or younger treated between 1980 and 1994 for noncardiac gastric cancer. The control group consisted of age- and sex-matched dyspeptic patients. The presence of H. pylori infection was assessed by modified Giemsa staining and immunostaining, using antibody against H. pylori.

RESULTS

H. pylori was found in 36 (72%; 95% confidence interval 60-84%) cancer patients and in 22 (43%; 30-58%) control patients (p = 0.0023, chi-square test). The odds ratio was 3.27 (1.42-7.52). Nonatrophic (superficial) gastritis was present in 30 (60%) cancer patients and in 19 (38%) (p = 0.028, chi-square test) control cases.

CONCLUSIONS

The results of the present study support the hypothesis that H. pylori is a risk factor for gastric cancer also in young age groups and in patients with a diffuse type of gastric cancer.

Early localization of necrosis by contrast-enhanced computed tomography can predict outcome in severe acute pancreatitis

A total of 161 primary contrast-enhanced computed tomography (CT) scans of patients with acute necrotizing pancreatitis taken between 1982 and 1994 were analysed retrospectively. The aim was to assess the prognostic significance of the extent and anatomical site of pancreatic tissue necrosis in the first contrast-enhanced CT scan. The scans were obtained a mean of 2.9 days after the onset of symptoms. The pancreatic head was affected in 107 patients, the body in 119 and the tail in 138. Pancreatic tissue necrosis, when divided into four groups according to anatomical site, correlated with overall clinical outcome. The anatomical site of necrosis was clearly better than its crude extent in predicting the risk of complications. For patients with necrosis in the head of the pancreas, the outcome was as severe as when the entire pancreas was affected. In contrast, for patients with necrosis only in the distal part of the pancreas, the outcome was favourable with few complications. The exact site of pancreatic tissue necrosis should be known when early contrast-enhanced CT is used in prognostic scoring.

Serum trypsinogen-2 and trypsin-2-alpha(1)-antitrypsin complex in malignant and benign digestive-tract diseases. Preferential elevation in patients with cholangiocarcinomas

Serum concentrations of trypsinogen-2 and trypsin-2-alpha(1)-antitrypsin (trypsin-2-AAT) were determined in 145 patients with malignant and 61 with benign digestive-tract diseases. The validity of these tests for detection of cancer was compared with that of CA 19-9 and CEA. Elevated levels of trypsinogen-2 (>90 micrograms/l) and trypsin-2-AAT (>25 micrograms/l) were found in 46% and 42%, respectively, of patients with malignant disease and the levels of trypsinogen-2 were significantly higher than in those with benign disease (p<0.005). High trypsinogen-2 and trypsin-2-AAT concentrations were found most often in patients with biliary and pancreatic cancer, but also in benign obstructive biliary disease. Our results suggest that trypsinogen-2 and trypsin-2-AAT are new potential markers for cholangiocarcinomas.

Serum trypsinogen-2 and trypsin-2-alpha(1)-antitrypsin complex in malignant and benign digestive-tract diseases. Preferential elevation in patients with cholangiocarcinomas

Serum concentrations of trypsinogen-2 and trypsin-2-alpha(1)-antitrypsin (trypsin-2-AAT) were determined in 145 patients with malignant and 61 with benign digestive-tract diseases. The validity of these tests for detection of cancer was compared with that of CA 19-9 and CEA. Elevated levels of trypsinogen-2 (>90 micrograms/l) and trypsin-2-AAT (>25 micrograms/l) were found in 46% and 42%, respectively, of patients with malignant disease and the levels of trypsinogen-2 were significantly higher than in those with benign disease (p<0.005). High trypsinogen-2 and trypsin-2-AAT concentrations were found most often in patients with biliary and pancreatic cancer, but also in benign obstructive biliary disease. Our results suggest that trypsinogen-2 and trypsin-2-AAT are new potential markers for cholangiocarcinomas.

Urine trypsinogen-2 as marker of acute pancreatitis

We examined the clinical utility of urine trypsinogen-2 as a marker of acute pancreatitis (AP). Fifty-nine patients with AP, 42 with acute abdominal diseases of extrapancreatic origin, and 63 without evidence of acute abdominal disease were studied. Urine trypsinogen-2 was determined by a time-resolved immunofluorometric assay. As reference methods we used serum trypsinogen-2, urine amylase, and serum amylase. The diagnostic accuracy of the markers was evaluated by receiver-operating characteristic (ROC) analysis. At admission, urine trypsinogen-2 differentiated patients with AP from controls with high accuracy. The area under the ROC curve (AUC) was 0.978, which was equal to that of serum trypsinogen-2 (0.998) and serum amylase (0.969) and significantly larger than that of urine amylase. For differentiation between severe and mild AP, urine trypsinogen-2 (0.730) was equal to serum trypsinogen-2 (0.721), and clearly better than amylase in serum and urine. These results suggest that determination of urine trypsinogen-2 is a useful test to detect AP and to evaluate disease severity.

Urine trypsinogen-2 as marker of acute pancreatitis

We examined the clinical utility of urine trypsinogen-2 as a marker of acute pancreatitis (AP). Fifty-nine patients with AP, 42 with acute abdominal diseases of extrapancreatic origin, and 63 without evidence of acute abdominal disease were studied. Urine trypsinogen-2 was determined by a time-resolved immunofluorometric assay. As reference methods we used serum trypsinogen-2, urine amylase, and serum amylase. The diagnostic accuracy of the markers was evaluated by receiver-operating characteristic (ROC) analysis. At admission, urine trypsinogen-2 differentiated patients with AP from controls with high accuracy. The area under the ROC curve (AUC) was 0.978, which was equal to that of serum trypsinogen-2 (0.998) and serum amylase (0.969) and significantly larger than that of urine amylase. For differentiation between severe and mild AP, urine trypsinogen-2 (0.730) was equal to serum trypsinogen-2 (0.721), and clearly better than amylase in serum and urine. These results suggest that determination of urine trypsinogen-2 is a useful test to detect AP and to evaluate disease severity.

Urinary trypsinogen-2 test strip for acute pancreatitis

BACKGROUND

A simple, rapid test is specific and sensitive enough to distinguish, in patients with clinically suspected acute pancreatitis, those whose abdominal pain is indeed of pancreatic origin has proved elusive.

METHODS

In two consecutive series of surgical patients in a teaching hospital, whose acute abdominal pain turned out to be due to acute pancreatitis (n-57) or extrapancreatic in origin (n=40), we studied urinary trypsinogen-2 in two ways. A test strip, incorporating monoclonal antibodies to two epitopes on trypsinogen-2, recorded a blue line when concentrations exceeded 50 microgram/L; we also measured trypsinogen-2 concentrations in the laboratory.

FINDINGS

In the patients with acute pancreatitis the test strip was positive in 52 and negative in five, whereas in the 40 extrapancreatic controls there were four false positives. In a further set of 57 orthopaedic controls, one urine was strip-test positive. Concentrations of urinary trypsinogen-2 and the test-strip results were in good agreement and in only three of the 154 patients were the two approaches discrepant, at the 50 microgram/L cut-off.

INTERPRETATION

These findings, in patients whose acute abdominal pain was known to be pancreatic in origin or not, are encouraging but need to be confirmed in a consecutive series of patients in whom the diagnosis of pancreatitis is in doubt.

Early antibiotic treatment in acute necrotising pancreatitis

Despite improvements in surgical treatment and intensive care, mortality from severe acute pancreatitis remains high. We have carried out a randomised study of 60 consecutive patients with alcohol-induced necrotising pancreatitis to find out whether early antibiotic treatment can improve outcome. 30 patients were assigned cefuroxime (4.5 g/day intravenously) from admission. In the second group, no antibiotic treatment was given until clinical or microbiologically verified infection or after a secondary rise in C-reactive protein. The inclusion criteria were C-reactive protein concentration above 120 mg/L within 48 h of admission and low enhancement (< 30 Hounsfield units) on contrast-enhanced computed tomography. There were more infectious complications in the non-antibiotic than in the antibiotic group (mean per patient 1.8 vs 1.0, p = 0.01). The most common cause of sepsis was Staphylococcus epidermidis; positive cultures were obtained from pancreatic necrosis or the central venous line in 14 of 18 patients with suspected but blood-culture-negative sepsis. Mortality was higher in the non-antibiotic group (seven vs one in the antibiotic group; p = 0.03). Four of the eight patients who died had cultures from pancreatic necrosis positive for Staph epidermidis. We conclude that cefuroxime given early in necrotising pancreatitis is beneficial and may reduce mortality, probably by decreasing the frequency of sepsis.

Comparison of high-field magnetic resonance imaging with computed tomography in the evaluation of blunt renal trauma

OBJECTIVE

To compare magnetic resonance (MR) imaging and computed tomography (CT) in radiographic staging of blunt renal trauma.

DESIGN

A prospective study.

MATERIALS AND METHODS

Fourteen patients with blunt renal trauma not requiring early surgical treatment underwent CT, and high-field (1.0 T) MR imaging.

MEASUREMENTS AND MAIN RESULTS

MR imaging equaled CT in correctly grading the renal injury. The coronal and sagittal projections of MR imaging were helpful in determining the extent of the renal parenchymal lesion. Both methods were accurate in finding perirenal hematomas, assessing the viability of renal fragments, and detecting pre-existing renal abnormalities, but failed to visualize urinary extravasation on initial examination.

CONCLUSIONS

Although CT remains the method of choice in radiographic staging of renal injury, MR imaging can complement CT in patients with severe renal injury, pre-existing renal abnormality, equivocal CT findings, or when repeated radiographic follow-up is required. MR imaging could replace CT in patients with iodine allergy and be used for initial staging if CT is not available.

Complications of negative laparotomy for truncal stab wounds

In a retrospective study of 459 patients undergoing mandatory explorative laparotomy for truncal stab wounds, 172 (37%) negative laparotomies were identified, divided in two groups: group I (n = 147) without, and group II (n = 25) with associated extra-abdominal injuries or surgical procedures other than laparotomy. One patient (0.6%) died of associated mediastinal vascular injuries. The overall postoperative morbidity rate was 21%, 17% in group I, and 44% in group II (p < 0.001). The excess morbidity in group II was caused by pulmonary complications associated with a thoracic injury or procedure. In group I, the complications were not severe, prolonging the mean hospital stay by 4.6 days. It is concluded that mandatory laparotomy for truncal stab wounds leads to an unnecessary operation in about 40% of cases, with a 20% morbidity rate associated with the laparotomy itself. Although the complications are not severe, the results should be assessed against the safety and accuracy of the selective management of abdominal stab wounds.

Stab wounds of the colon

In a retrospective analysis of 38 patients with stab wounds of the colon, 89% of the colon wounds involved only up to one fourth of the wall. One third of the patients had no other abdominal organ injuries. All patients were operated on within 11 hours from the injury. The method of management of the colon wound was based on the surgeon's individual assessment, with 76% undergoing primary repair. The significant factors favouring a colostomy over primary repair were the older age of the patient (P = 0.04), and the longer delay from trauma to the operation (P = 0.01). The overall complication rate was 32% with no mortality. Four patients (11%) developed colon-related infection complications. The hospital stay after primary repair was on average 15 days shorter than after colostomy including colostomy closure time (P < 0.001). In conclusion, stab wounds of the colon are usually mild injuries and can be managed safely with early primary repair.

Piperacillin/tazobactam versus imipenem/cilastatin in the treatment of intra-abdominal infections

The current multicenter study was conducted at five sites using 86 patients to evaluate the safety and efficacy of piperacillin/tazobactam (4 grams per 500 milligrams every eight hours) compared with imipenem/cilastatin (1 gram every eight hours) in the treatment of patients who were hospitalized with a clinically or bacteriologically confirmed diagnosis of intra-abdominal infection. Forty-seven patients received piperacillin/tazobactam and 39 received imipenem/cilastatin. The favorable response among patients who were clinically evaluable with a valid response in the group treated with piperacillin/tazobactam was 87 percent. In the group treated with imipenem/cilastatin it was 77 percent. Bacteriologic eradication rate among bacteriologically evaluable patients with a valid response in the group treated with piperacillin/tazobactam was 100 percent. In the group treated with imipenem/cilastatin it was 89 percent. The eradication rate of pathogens isolated from patients who were evaluable by biologic factors in the group treated with piperacillin/tazobactam was 100 percent and in the group treated with imipenem/cilastatin treatment, 96 percent. In the group treated with piperacillin/tazobactam the incidence and type of adverse reactions were similar to those seen with piperacillin alone. It is concluded that piperacillin/tazobactam is safe and efficacious in the treatment of patients hospitalized with intraabdominal infections and that tazobactam extends the spectrum of piperacillin.

Acalculous cholecystitis after bone marrow transplantation in adults with acute leukaemia. Case report

In three adults with acute leukaemia, acalculous cholecystitis was diagnosed with ultrasonography soon after bone marrow transplantation. The clinical picture of cholecystitis was progressive, and cholecystectomy was performed in all cases despite anaemia, granulocytopenia and thrombocytopenia. Postoperative recovery was uncomplicated.

Orchiectomy versus oestrogen in the treatment of advanced prostatic cancer

The primary clinical efficacy of orchiectomy and the combination therapy of intramuscular polyoestradiol phosphate 80 mg monthly and oral ethinyl oestradiol 0.15 mg daily was evaluated by progression and cancer mortality rates in a series of 277 prostatic cancer patients representing part of the Finnprostate study. After a follow-up of 5 years there was a significant difference between the groups in terms of progression rate and prostatic cancer deaths. The oestrogen combination was more effective in delaying progression of the disease. The overall mortality rate was similar in both groups. About one-third of the patients were alive after 5 years.

Diagnostic evaluation and aggressive surgical approach in bleeding pseudoaneurysms associated with pancreatic pseudocysts

Hemorrhage is an uncommon but serious complication of pancreatic pseudocysts. When gastrointestinal bleeding or intra-abdominal hemorrhage is associated with a pancreatic pseudocyst and the usual sources of bleeding are not detected by endoscopy, the rupture of a pseudoaneurysm inside the pseudocyst should be suspected. We present 13 cases, 11 associated with chronic and 2 with late complications after acute necrotizing pancreatitis. On the basis of sonographic findings, bleeding site was suspected in 8 of 11 patients (73%). Computed tomography (CT) was performed on 10, and bleeding was suspected in 8 (80%). The pseudoaneurysm itself was detected by CT in one and by ultrasonography in none. Visceral angiography was performed on five patients, and the pseudoaneurysm was evident in all. External drainage with arterial ligation was done as a primary operation in five patients; four of them later underwent pancreatic resection because of rebleeding. In eight cases pancreatic resection was the initial operation; none of these patients continued to bleed or needed reoperation because of the same pseudoaneurysm. There were no intraoperative deaths, but one patient died postoperatively. Aggressive diagnostic evaluation and surgical approach are associated with a reduction in mortality and morbidity in this serious complication of pancreatic pseudocysts.

Comparison of endoscopic Nd:YAG laser therapy and oesophageal tube in palliation of oesophagogastric malignancy

The clinical results of 96 patients with upper gastrointestinal malignancy have been evaluated retrospectively. Sixty-nine patients with a mean age of 72 years (35 men and 34 women) were treated with endoscopic laser therapy, and 27 patients with a mean age of 67 years (16 men and 11 women) with insertion of an oesophageal tube. After laser therapy the bulk of the tumour was reduced in 87%, and in 55% clear signs of relieved dysphagia were seen. The insertion of an oesophageal tube was successful in 89%. In the laser group no fatal complications occurred, and the overall complication risk was 8.7%. The 1-year survival in all laser patients was 12%, and in patients with impassable tumour stenosis the survival was 6%. The mortality related to the insertion of an oesophageal tube was 11%, and complications occurred in 48% of the patients. The 1-year survival of the tube group was nil. It is concluded that endoscopic laser therapy and insertion of oesophageal tube are both effective methods in palliation of oesophagogastric malignancy, but the mortality and risk for complications were markedly lower after laser therapy.