Multiple Layers of Complexity in O-Glycosylation Illustrated With the Urinary Glycoproteome

While N-glycopeptides are relatively easy to characterize, O-glycosylation analysis is more complex. In this article, we illustrate the multiple layers of O-glycopeptide characterization that make this task so challenging. We believe our carefully curated dataset represents perhaps the largest intact human glycopeptide mixture derived from individuals, not from cell lines. The samples were collected from healthy individuals, patients with superficial or advanced bladder cancer (three of each group), and a single bladder inflammation patient. The data were scrutinized manually and interpreted using three different search engines: Byonic, Protein Prospector, and O-Pair, and the tool MS-Filter. Despite all the recent advances, reliable automatic O-glycopeptide assignment has not been solved yet. Our data reveal such diversity of site-specific O-glycosylation that has not been presented before. In addition to the potential biological implications, this dataset should be a valuable resource for software developers in the same way as some of our previously released data has been used in the development of O-Pair and O-Glycoproteome Analyzer. Based on the manual evaluation of the performance of the existing tools with our data, we lined up a series of recommendations that if implemented could significantly improve the reliability of glycopeptide assignments.

Community evaluation of glycoproteomics informatics solutions reveals high-performance search strategies for serum glycopeptide analysis

Glycoproteomics is a powerful yet analytically challenging research tool. Software packages aiding the interpretation of complex glycopeptide tandem mass spectra have appeared, but their relative performance remains untested. Conducted through the HUPO Human Glycoproteomics Initiative, this community study, comprising both developers and users of glycoproteomics software, evaluates solutions for system-wide glycopeptide analysis. The same mass spectrometrybased glycoproteomics datasets from human serum were shared with participants and the relative team performance for N- and O-glycopeptide data analysis was comprehensively established by orthogonal performance tests. Although the results were variable, several high-performance glycoproteomics informatics strategies were identified. Deep analysis of the data revealed key performance-associated search parameters and led to recommendations for improved 'high-coverage' and 'high-accuracy' glycoproteomics search solutions. This study concludes that diverse software packages for comprehensive glycopeptide data analysis exist, points to several high-performance search strategies and specifies key variables that will guide future software developments and assist informatics decision-making in glycoproteomics.

The effectiveness of filtering glycopeptide peak list files for Y ions

Intact glycopeptide analysis is becoming more common with developments in mass spectrometry instrumentation and fragmentation approaches. In particular, collision-based fragmentation approaches such as higher energy collisional dissociation (HCD) and radical-driven fragmentation approaches such as electron transfer dissociation (ETD) provide complementary information, but bioinformatic strategies to utilize this combined information are currently lacking. In this work we adapted a software tool, MS-Filter, to search HCD peak list files for predicted Y ions based on matched EThcD results to propose additional glycopeptide assignments. The strategy proved to be extremely powerful for O-glycopeptide data, and also of benefit for N-linked data, where it allowed rescue of low confidence results from database searching.

Novel O-linked sialoglycan structures in human urinary glycoproteins

Glycopeptides represent cross-linked structures between chemically and physically different biomolecules. Mass spectrometric analysis of O-glycopeptides may reveal the identity of the peptide, the composition of the glycan and even the connection between certain sugar units, but usually only the combination of different MS/MS techniques provides sufficient information for reliable assignment. Currently, HCD analysis followed by diagnostic sugar fragment-triggered ETD or EThcD experiments is the most promising data acquisition protocol. However, the information content of the different MS/MS data is handled separately by search engines. We are convinced that these data should be used in concert, as we demonstrate in the present study. First, glycopeptides bearing the most common glycans can be identified from EThcD and/or HCD data. Then, searching for Y₀ (the gas-phase deglycosylated peptide) in HCD spectra, the potential glycoforms of these glycopeptides could be lined up. Finally, these spectra and the corresponding EThcD data can be used to verify or discard the tentative assignments and to obtain further structural information about the glycans. We present 18 novel human urinary sialoglycan structures deciphered using this approach. To accomplish this in an automated fashion further software development is necessary.

New near-infrared rhodamine dyes with large Stokes shifts for sensitive sensing of intracellular pH changes and fluctuations

New near-infrared rhodamine dyes with large Stokes shifts were developed and applied for sensitive detection of cellular pH changes and fluctuations by incorporating an additional amine group with fused rings into the rhodamine dyes to enhance the electron donating ability of amine groups and improve the spectroscopic properties of the dyes.

Status Report on the High-Throughput Characterization of Complex Intact O-Glycopeptide Mixtures

A very complex mixture of intact, human N- and O-glycopeptides, enriched from the tryptic digest of urinary proteins of three healthy donors using a two-step lectin affinity enrichment, was analyzed by LC-MS/MS, leading to approximately 45,000 glycopeptide EThcD spectra. Two search engines, Byonic and Protein Prospector, were used for the interpretation of the data, and N- and O-linked glycopeptides were assigned from separate searches. The identification rate was very low in all searches, even when results were combined. Thus, we investigated the reasons why was it so, to help to improve the identification success rate. Focusing on O-linked glycopeptides, we noticed that in EThcD, larger glycan oxonium ions better survive the activation than those in HCD. These fragments, combined with reducing terminal Y ions, provide important information about the glycan(s) present, so we investigated whether filtering the peaklists for glycan oxonium ions indicating the presence of a tetra- or hexasaccharide structure would help to reveal all molecules containing such glycans. Our study showed that intact glycans frequently do not survive even mild supplemental activation, meaning one cannot rely on these oxonium ions exclusively. We found that ETD efficiency is still a limiting factor, and for highly glycosylated peptides, the only information revealed in EThcD was related to the glycan structures. The limited overlap of results delivered by the two search engines draws attention to the fact that automated data interpretation of O-linked glycopeptides is not even close to being solved. Graphical abstract ᅟ.

Using "spectral families" to assess the reproducibility of glycopeptide enrichment: human serum O-glycosylation revisited

Growing evidence on the diverse biological roles of extracellular glycosylation as well as the need for quality control of protein pharmaceuticals make glycopeptide analysis both exciting and important again after a long hiatus. High-throughput O-glycosylation studies have to tackle the complexity of glycosylation as well as technical difficulties and, up to now, have yielded only limited results mostly from single enrichment experiments. In this study, we address the technical reproducibility of the characterization of the most prevalent O-glycosylation (mucin-type core 1 structures) in human serum, using a two-step lectin affinity-based workflow. Our results are based on automated glycopeptide identifications from higher-energy C-trap dissociation and electron transfer dissociation MS/MS data. Assignments meeting strict acceptance criteria served as the foundation for generating "spectral families" incorporating low-scoring MS/MS identifications, supported by accurate mass measurements and expected chromatographic retention times. We show that this approach helped to evaluate the reproducibility of the glycopeptide enrichment more reliably and also contributed to the expansion of the glycoform repertoire of already identified glycosylated sequences. The roadblocks hindering more in-depth investigations and quantitative analyses will also be discussed.

Randomised clinical trial: a 1-week, double-blind, placebo-controlled study of pancreatin 25 000 Ph. Eur. minimicrospheres (Creon 25000 MMS) for pancreatic exocrine insufficiency after pancreatic surgery, with a 1-year open-label extension

BACKGROUND

Pancreatic exocrine insufficiency (PEI) often occurs following pancreatic surgery.

AIM

To demonstrate the superior efficacy of pancreatin 25 000 minimicrospheres (Creon 25000 MMS; 9-15 capsules/day) over placebo in treating PEI after pancreatic resection.

METHODS

A 1-week, double-blind, randomised, placebo-controlled, parallel-group, multicentre study with a 1-year, open-label extension (OLE). Subjects ≥18 years old with PEI after pancreatic resection, defined as baseline coefficient of fat absorption (CFA) <80%, were randomised to oral pancreatin or placebo (9-15 capsules/day: 3 with main meals, 2 with snacks). In the OLE, all subjects received pancreatin. The primary efficacy measure was least squares mean CFA change from baseline to end of double-blind treatment (ancova).

RESULTS

All 58 subjects randomised (32 pancreatin, 26 placebo) completed double-blind treatment and entered the OLE; 51 completed the OLE. The least squares mean CFA change in the double-blind phase was significantly greater with pancreatin vs. placebo: 21.4% (95% CI: 13.7, 29.2) vs. -4.2% (-12.8, 4.5); difference 25.6% (13.9, 37.3), P < 0.001. The mean ± s.d. CFA increased from 53.6 ± 20.6% at baseline to 78.4 ± 20.7% at OLE end (P < 0.001). Treatment-emergent adverse events occurred in 37.5% subjects on pancreatin and 26.9% on placebo during double-blind treatment, with flatulence being the most common (pancreatin 12.5%, placebo 7.7%). Only two subjects discontinued due to treatment-emergent adverse events, both during the OLE.

CONCLUSIONS

This study demonstrates superior efficacy of pancreatin 25 000 over placebo in patients with PEI after pancreatic surgery, measured by change in CFA. Pancreatin was generally well tolerated at the high dose administered (EudraCT registration number: 2005-004854-29).

ESPEN Guidelines on Enteral Nutrition: Pancreas

The two major forms of inflammatory pancreatic diseases, acute and chronic pancreatitis, require different approaches in nutritional management, which are presented in the present guideline. This clinical practice guideline gives evidence-based recommendations for the use of ONS and TF in these patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. In mild acute pancreatitis enteral nutrition (EN) has no positive impact on the course of disease and is only recommended in patients who cannot consume normal food after 5-7 days. In severe necrotising pancreatitis EN is indicated and should be supplemented by parenteral nutrition if needed. In the majority of patients continuous TF with peptide-based formulae is possible. The jejunal route is recommended if gastric feeding is not tolerated. In chronic pancreatitis more than 80% of patients can be treated adequately with normal food supplemented by pancreatic enzymes. 10-15% of all patients require nutritional supplements, and in approximately 5% tube feeding is indicated.

Adjuvant chemoradiotherapy and chemotherapy in resectable pancreatic cancer: a randomised controlled trial

BACKGROUND

The role of adjuvant treatment in pancreatic cancer remains uncertain. The European Study Group for Pancreatic Cancer (ESPAC) assessed the roles of chemoradiotherapy and chemotherapy in a randomised study.

METHODS

After resection, patients were randomly assigned to adjuvant chemoradiotherapy (20 Gy in ten daily fractions over 2 weeks with 500 mg/m(2) fluorouracil intravenously on days 1-3, repeated after 2 weeks) or chemotherapy (intravenous fluorouracil 425 mg/m(2) and folinic acid 20 mg/m(2) daily for 5 days, monthly for 6 months). Clinicians could randomise patients into a two-by-two factorial design (observation, chemoradiotherapy alone, chemotherapy alone, or both) or into one of the main treatment comparisons (chemoradiotherapy versus no chemoradiotherapy or chemotherapy versus no chemotherapy). The primary endpoint was death, and all analyses were by intention to treat. Findings 541 eligible patients with pancreatic ductal adenocarcinoma were randomised: 285 in the two-by-two factorial design (70 chemoradiotherapy, 74 chemotherapy, 72 both, 69 observation); a further 68 patients were randomly assigned chemoradiotherapy or no chemoradiotherapy and 188 chemotherapy or no chemotherapy. Median follow-up of the 227 (42%) patients still alive was 10 months (range 0-62). Overall results showed no benefit for adjuvant chemoradiotherapy (median survival 15.5 months in 175 patients with chemoradiotherapy vs 16.1 months in 178 patients without; hazard ratio 1.18 [95% CI 0.90-1.55], p=0.24). There was evidence of a survival benefit for adjuvant chemotherapy (median survival 19.7 months in 238 patients with chemotherapy vs 14.0 months in 235 patients without; hazard ratio 0.66 [0.52-0.83], p=0.0005). Interpretation This study showed no survival benefit for adjuvant chemoradiotherapy but revealed a potential benefit for adjuvant chemotherapy, justifying further randomised controlled trials of adjuvant chemotherapy in pancreatic cancer.

Stimulated gastrointestinal hormone release and gallbladder contraction during continuous jejunal feeding in patients with pancreatic pseudocyst is inhibited by octreotide

BACKGROUND

Continuous enteral feeding, the old-new therapeutic modality in the treatment of patients with acute pancreatitis and those with complications is considered to bypass the cephalic, the gastric, and (at least in part) the intestinal phase of pancreatic secretion. The aim of this study was to test the GI hormonal changes and gallbladder motility during CJF in patients with pancreatic pseudocysts following acute pancreatitis, with or without octreotide pretreatment.

PATIENTS AND METHODS

In 15 patients with pancreatic pseudocysts, an 8-French (8F) nasojejunal catheter was positioned into the jejunum distal to the ligament of Treitz during duodenoscopy. On test d 1, blood samples were taken for CCK, gastrin, insulin-like immunoreactivity (IRI), glucagon, and glucose measurements prior to and at 20, 40, 60, and 120 min following jejunal saline infusion at a rate of 2 mL/min. The gallbladder volumes were determined simultaneously by ultrasonography. On test d 2, CJF (175 kcal/h) was started by the same route and at the same infusion rate. Analogous measurements were performed as indicated above. On test d 3, 100 microg of octreotide was administered subcutaneously and the previous procedure was repeated. The plasma level of CCK and glucagon and the serum levels of IRI and gastrin were determined by bioassay and radioimmunoassay (RIA), respectively.

RESULTS

Significant changes in hormone levels were not observed during jejunal saline perfusion. However, the levels of CCK (5.7+/-0.9 pmol), gastrin (10.6+/-1.3 pmol/L), IRI (27.2+/-5.8 microIU/mL), glucagon (322.8+/-32.4 pg/mL), and glucose (5.8+/-1.0 mmol/L) were significantly increased at 20 min during CJF vs the saline controls (2.0+/-0.3 pmol, 6.8+/-1.1 pmol/L, 7.8+/-0.4 microIU/mL, 172.8+/-33.4 pg/mL, and 4.5+/-0.5 mmol/L, respectively) and remained elevated at 40, 60, and 120 min. Octreotide pretreatment eliminated the increases in CCK, gastrin, IRI, and glucagon levels observed during CJF alone. The significant decrease in gallbladder volume during CJF was also prevented by octreotide pretreatment.

CONCLUSION

Continuous jejunal feeding (CJF) elicited significant increases in gastrointestinal (GI) regulatory hormone (cholecystokinin [CCK], gastrin, IRI, and glucagon) levels and evoked a consecutive gallbladder contraction. These biological responses are eliminated by octreotide pretreatment. Further clinical studies are needed to assess the eventual therapeutic effect of octreotide during CJF in patients with pancreatic pseudocyst.

Thrombosis in Behçet's disease: a retrospective survey from a single UK centre

OBJECTIVE

To contribute to knowledge of vascular occlusion in Behçet's disease (BD), prevalence and relative risk for thrombosis were ascertained retrospectively in a cohort of Caucasian patients with the disease.

PATIENTS

The study included 73 BD patients (36 males, 37 females, mean age 45+/-11 yr) attending the Immunology/Rheumatology Department of Northwick Park Hospital. A group of 146 patients without BD, attending the same department, served as a control group.

RESULTS

Thrombosis was more frequent in BD patients than in controls (23/73, 32% vs 7/146, 5%, P<0.001). This was accounted for by a higher prevalence of venous thrombosis in BD patients (18/73, 25% vs 4/146, 3%, P<0.001). Gender-adjusted data revealed an 11-fold risk of developing any thrombosis and a 14-fold risk of developing venous thrombosis in BD. After adjusting for differences in age at first symptoms, male BD patients showed a 6-fold higher risk of vein thrombosis. Males reported more often thrombophlebitis (13/36, 36% vs 0/0, P<0.001), folliculitis (8/36, 22% vs 1/37, 3%, P<0.01) and retinal vasculitis (13/36, 36%, vs 4/37, 11%, P=0.01) than females, in whom arthralgia prevailed (23/37, 62%, vs 12/36, 33%, P=0.01).

CONCLUSION

In our population, BD confers a 14-fold risk of developing venous thrombosis. The risk is sixfold higher in male BD patients, who fare worse than females with regard to thrombophlebitis, folliculitis and retinal vasculitis.

Jejunal feeding in chronic pancreatitis with severe necrosis

CONTEXT

Necrotizing pancreatitis is the most serious form of pancreatic inflammatory disease leading to multiorgan failure and a high (15-20%) mortality rate. The poor nutritional and metabolic conditions and secondary bacterial translocation raise the mortality rate even more.

OBJECTIVE

The aim of the study was to evaluate the effect of jejunal feeding in cases of chronic pancreatitis with extended necrosis.

PATIENTS

In our institution, over a five-year period, 86 patients with severe necrotizing pancreatitis were treated for extended necrosis. In 19 patients, chronic calcifying pancreatitis was demonstrated by computed tomography showing more than 20% necrosis in the residual pancreas as well.

SETTING

In 12 cases, nutrition was provided by jejunal feeding using an endoscopically placed nasojejunal feeding tube, whereas in 7 cases, hypocaloric parenteral nutrition was used.

DESIGN

Retrospective unicenter study.

MAIN OUTCOME MEASURES

The rate of healing with conservative treatment.

RESULTS

Two of the 12 jejunally fed patients were operated on because of complications of pancreatitis. Five patients required intervention in the hypocaloric parenteral nutrition group: 4 were operated on and one more needed endoscopic intervention. The healing rate was significantly higher (P=0.045) in the jejunal feeding group (83.3%) than in the parenteral nutrition (28.6%) patients.

CONCLUSIONS

In cases of chronic calcifying pancreatitis serious necrosis can develop in the residual pancreas resulting in a severe acute pancreatitis-like disease. A better healing rate was achieved and less interventions became necessary using nasojejunal tube feeding than in the parenteral nutrition group and this was analogous to what was observed in severe necrotizing pancreatitis This form of pancreatitis has not yet been described in the literature in detail. The authors suggest that it be regarded as a separate entity.

Antiproliferative efficacy of the somatostatin analogue TT-232 in human melanoma cells and tumours

BACKGROUND

TT-232, a somatostatin analogue, induces apoptosis in various tumours. The aim of our study was to characterise its effect on human melanoma cells and tumours.

MATERIALS AND METHODS

Proliferation of seven melanoma cell lines was tested in vitro with the methylene blue test. D10 and 205 cells were also implanted into CB17-scid mice which received 30-150-750 micrograms/kg/day of TT-232 or saline. Animals with 205 cells received twice-daily subcutaneous injections whereas animals with D10 cells were treated with osmotic mini-pumps. In addition, TT-232 metabolites were generated with tissue homogenates and tested in vitro.

RESULTS

TT-232 strongly inhibited proliferation of all cell lines in vitro and tumour growth in vivo. Two out of 8 animals (30-150 micrograms/kg) in the 205 model and one out of 8(150 micrograms/kg) in the D10 model became completely tumour-free at the 11th and 9th day of treatment, respectively. TT-232 was degraded only by liver homogenate whilst its metabolite had no antiproliferative effect in vitro.

CONCLUSIONS

TT-232 is a promising drug candidate for melanoma.

Effects of lorglumide and atropine on MgSO(4)-induced gallbladder emptying in conscious dogs

The aim of the study was to examine the possible involvement of cholecystokinin (by lorglumide) and cholinergic mechanisms (by atropine) in magnesium sulphate (MgSO(4))-induced gallbladder contraction of conscious dogs. The gallbladder (GB) volume was determined by ultrasonography. The optimal dose of 80 mg kg(-1)of MgSO(4)was determined from a MgSO(4)dose-response curve using doses of 10, 20,40, 80, 120 mg kg(-1). The largest dose of MgSO(4)was less effective than the optimal dose. Peak gallbladder contraction (32 per cent) was achieved at 30 minutes. Atropine (50 microg kg(-1)s.c.) or lorglumide (1 mg kg(-1)p.o.) fully prevented GB contraction. In conclusion, supraoptimal doses of MgSO(4)have a diminishing effect. The sustained contraction of the gallbladder in response to the optimal dose of MgSO(4)can be explained by an additive effect of the cholecystokinin release and a cholinergic trigger mechanism. Ultrasonography and MgSO(4)stimulation proved to be a valuable technique for examination of gallbladder motility.

Influence of various administration routes on the antitumor efficacy ofTT-232, a novel somatostatin analog

TT-232 a novel tumor-selective somatostatin analog with a five residue ring structure (D-Phe-Cys-Tyr-D-Trp-Lys-Cys-Thr-NH2) was developed by us and published in an earlier work. This synthetic heptapeptide had no effect on growth hormone release, but had a remarkable tyrosine-kinase inhibitory effect and inducted apoptosis. The aim of this study was to compare the therapeutic efficacy of TT-232 used in various long-term administration routes and treatment schedules. The effectiveness of TT-232 was studied on different rodent tumors transplanted to inbred mice from SPF breeding. Intermittent treatment by injections and continuous infusion of TT-232 using a s.c., i.p. or i.v. implanted Alzet type osmotic minipump were compared for therapeutic efficacy. The treatments were started either on the day subsequent to tumor transplantation or after the development of a tumor. On the basis of survival and tumor growth inhibition the infusion of TT-232 for 14 days using an implantable osmotic pump proved to be a much more effective route of treatment in both s.c. and i.v. administration than the intermittent injections applied twice a day for 2 weeks. In the case of S-180 sarcoma the continuous administration of TT-232 for 14 days using s.c. implanted osmotic pump resulted in 60% the i.v. infusion produced 40% long-term (over 80 days) and tumor free survivors. By the continuous administration of TT-232, an 80-100% tumor growth inhibitory effect and a considerable retardation of tumor development could be achieved. Continuous infusion from implanted pumps ensured a constant drug level and resulted in a well-defined, consistent pattern of drug exposure over the full duration of drug administration. In our study the route of infusion has been shown to increase drug efficacy relative to conventional delivery methods.

[Use of two teflon stents in malignant non-hilar biliary atresia]

Insertion of biliary stents in cases of malignant biliary obstruction is a widely accepted method to resolve jaundice. The authors applied two 10 French biliary teflon stents to prolong the drain patency in 32 patients with distal malignant obstruction, thought to be inoperable at the time of intervention. Among the followed, inoperable 23 cases 14 patients died for the time of evaluation. The median survival was 150 days, the median drain patency was 99 days. Cholangitis was the cause of death in three patients. Repeated endoscopic interventions were: transient nasobiliary drainage without drain replacement in two patients and four changes of stents in three patients. In the 13 patients, surviving and wearing their drains at least for 100 days the patency of the double drains was 157 days. These results obtained in the long-time survivors support the comparability of the patency of double teflon stent to that of metalstents. In majority of cases the two teflon drains remained patent until the deaths of patients.

Non-surgical treatment of biliary liver abscesses: efficacy of endoscopic drainage and local antibiotic lavage with nasobiliary catheter

BACKGROUND

It is universally recognized that the most frequent cause of hepatic abscess is biliary disease. The aim of this study was to determine the efficacy of endoscopic drainage and local antibiotic lavage via nasobiliary catheter in the treatment of liver abscesses of biliary origin.

METHOD

From January 1994 to December 1995, twenty-two cases of pyogenic liver abscess were treated. Diagnosis was established with ultrasound, computed tomography, endoscopic retrograde cholangiography, and laboratory tests. All patients were assigned prospectively to endoscopic or other non-surgical forms of therapy, depending on the etiology of the pyogenic process. Patients in whom this treatment failed underwent surgical drainage. Twenty patients had hepatic abscesses of biliary origin. In this subgroup, a nasobiliary catheter was placed into the biliary tree for continuous antibiotic lavage (infusion technique: 1 to 1.5 mL/min for 8 to 10 days) after endoscopic sphincterotomy. Two patients had hepatic abscesses of hematogenous and amebic origin, respectively. They were treated only with the appropriate systemic antibiotics.

RESULTS

Nineteen patients of the biliary subgroup (95%) and the two patients with non-biliary disease (100%) had complete resolution of the abscesses. "Salvage" surgical drainage was required in only one patient (4.5%). There was no treatment related mortality.

CONCLUSION

Endoscopic sphincterotomy and local antibiotic lavage via an endoscopically placed nasobiliary catheter is a safe and effective treatment for biliary liver abscesses. It should be considered as first-line treatment in this subgroup of patients with liver abscesses. Percutaneous or surgical drainage modalities should be reserved for patients in whom endoscopic treatment fails.

Sequential treatment of the common bile duct stones and cholecystolithiasis

The orthodox method of the treatment of gallstone disease is laparoscopic cholecystectomy (LC) days or weeks after endoscopic retrograde cholangiopancreatography + endoscopic spincterotomy (ERCP+ES). It can be advantageous from the point of financing, that is double reimbursement (2 x DRG). On the other hand there are some disadvantages of this procedure: longer hospital stay, further suffering of the patient, difficulties at operation because of inflammation provoked by ERCP (11% 14/120 in 3 month). We report on our experience with the treatment of common bile duct stones within 24 h by sequential endoscopic-laparoscopic management. The gallstone disease of a 32 year old woman was diagnosed by ultrasonography and laboratory tests. She had ERCP+ES in the morning and LC 7 hours later. There was no complication and the patient was discharged already on the 3rd day.

Jejunal feeding in necrotising acute pancreatitis--a retrospective study

The acute necrotising pancreatitis is the most serious form of pancreatic inflammatory disease leading to multiorgan failure and high (15-20%) mortality. The poor nutritional and metabolic condition and secondary bacterial translocation rise the mortality further on. A newly introduced clinical method of continuous nasojejunal feeding-based on experimental works--resulted in lower mortality rate (less than 4%) by perfusing adequate nutrients into the second loop of jejunum via a feeding tube. The better nutritional and immunological status of the patients, with restored absorption and intestinal motility promoted recovery, and prevented the septic complications. Although in some cases with serious progression operation became necessary; the timing of surgery was easier because of the less fragile state of the patient. The continuous nasojejunal feeding is a promising new method among the therapeutic modalities of the acute pancreatitis.

Efficacy of two different dosage regimens of omeprazole, amoxycillin and metronidazole for the cure of Helicobacter pylori infection

BACKGROUND

While addition of metronidazole to the omeprazole-amoxycillin combination has been shown to be advantageous, the optimal dosage and drug distribution of the antimicrobials has not been sufficiently evaluated.

AIM

To investigate the efficacy of two different regimens of omeprazole, amoxycillin and metronidazole for the cure of Helicobacter pylori infection.

METHODS

Two hundred and fifty-five patients with H. pylori associated duodenal ulcers were randomly treated with either a 1-week regimen of omeprazole 20 mg b.d., amoxycillin 1000 mg b.d. and metronidazole 800 mg b.d. (OAM b.d.) or a combination of omeprazole 40 mg o.d., amoxycillin 500 mg t.d.s. and metronidazole 400 mg t.d.s. (OAM t.d.s.). All patients subsequently received omeprazole 20 mg o.d. for an additional 3 weeks. H. pylori status was assessed by histology and 13C-UBT prior to treatment and 8 weeks after randomization. Additional biopsies were obtained for H. pylori culture to determine primary and secondary resistance to metronidazole by agar dilution.

RESULTS

Two hundred and thirty-seven patients were included in the intention-to-treat analysis and 198 patients in the per protocol analysis. With intention-to-treat analysis, the cure rate was 77% after treatment with OAM b.d. (95% CI, 69%-85%) and 76% after OAM t. d.s. therapy (95% CI, 67%-83%). Ulcer healing (intention-to-treat analysis) was documented in 95% of patients in the OAM b.d. group (n=122) and in 97% of patients in the OAM t.d.s. group (n=115). Adverse events were reported in 26 (20%) and in 18 (14%) patients in the OAM b.d. and OAM t.d.s. groups, respectively. None resulted in discontinuation of treatment. Overall primary resistance of H. pylori against metronidazole was found in 22 of 116 strains (19%).

CONCLUSIONS

The combination of omeprazole, amoxycillin and metronidazole achieves about an 80% cure rate of H. pylori infection even in active ulcers. The total daily dose, and the choice of twice or three times daily dosing does not seem critical with this regimen.

In vivo antitumor activity of TT-232 a novel somatostatin analog

The somatostatin analog TT-232 containing a 5 residue ring, was previously shown to inhibit the proliferation of a large number of cancer cell lines in vitro and reduce the size of tumors in animal models in vivo. Its action is accompanied by inhibition of tyrosine kinases and is characterized by the induction of programmed cell death. On the other hand, it was proved to be free of the endocrine effects of the natural compound. The aim of this study was to find the optimal dose and administration route for in vivo tumor therapy in an animal model. We have investigated the dose--and administration route-dependent antitumor activity of TT-232 on S-180 sarcoma tumor transplanted to inbred BDF1 mice from SPF breeding. Long-term administration (i.p., s.c. and i.v. injections) was started either on the day subsequent to tumor transplantation or after the development of tumor. The antineoplastic potential of TT-232 was evaluated on the basis of survival and tumor growth inhibition. In long-term administration (injections twice a day for 2 weeks) a significant, but dose- and administration route-dependent therapeutic efficacy of TT-232 was observed. The optimum dose of TT-232 15 micrograms/kg which resulted in a 30-40% cure rate and 50-70% growth inhibition in S-180 sarcoma tumor. A moderate antitumor effect was achieved by TT-232 when it was administered after the evelopment of tumor. Our study suggests that TT-232 can be a promising antitumor agent.

Impact of functional dyspepsia on quality of life and health care consumption after cessation of antisecretory treatment. A multicentre 3-month follow-up study

BACKGROUND

The impact of response to treatment on subsequent symptoms, quality of life, health care consumption, and absence from work in functional dyspepsia is unknown.

METHODS

Patients with functional dyspepsia from Denmark, France, Germany, The Netherlands, Hungary, and Poland (n = 567 (215 men), 18-80 years old) were followed up for 3 months after a 4-week treatment trial with omeprazole (20 mg or 10 mg) or placebo. The patients were blinded to the initial treatment. Dyspeptic symptoms and quality of life were assessed, and dyspepsia-related costs were calculated in terms of number of clinic visits, days on medication, and absence from work.

RESULTS

Responders had fewer clinic visits than non-responders (1.5 versus 2.0 mean visits) and fewer days on medication (mean, 9 days versus 23 days) over the 3-month period (both, P < 0.001). The quality of life in responders was better at study entry and persisted over 3 months (all, P < 0.001). When analysed country by country, health care costs due to clinic visits and medications were significantly lower in responders in all countries (P < 0.05), except Denmark and The Netherlands.

CONCLUSION

Symptom resolution in patients with functional dyspepsia has a positive impact on quality of life and reduces the subsequent costs over a 3-month period after cessation of initial treatment.

Pain relief and functional recovery after endoscopic interventions for chronic pancreatitis

BACKGROUND

Pain and functional deterioration in chronic pancreatitis is multifactorial. Early surgery in non-alcoholic patients with mild to moderate chronic pancreatitis can relieve pain and prevent progression of pancreatic insufficiency for some time, but the good results are only short term. Endoscopic intervention can relieve pain and recover pancreatic function without surgery.

METHODS AND RESULTS

To achieve the burned out state of chronic pancreatitis, occlusion of the pancreatic duct was first attempted by our team with Ethibloc at ERCP. Temporary obstruction of the pancreatic duct did not result in a long-lasting symptom and relapse-free situation because of early recovery of pancreatic function. On the contrary, endoscopic simple and double papillotomy, pancreatic drainage with citrate lavage, biliary endoprosthesis with multiple stents and endoscopic decompression of pseudocysts with or without jejunal feeding resulted in pain-free patients for a considerable time and in several cases significant functional recovery occurred. In cases where pain remained, percutaneous celiac plexus block with long-lasting steroids can be applied and only if all of these treatments fail should surgery be recommended.

CONCLUSION

Endoscopic intervention can successfully substitute for surgery for chronic pancreatitis in individual cases.

Efficacy of omeprazole in functional dyspepsia: double-blind, randomized, placebo-controlled trials (the Bond and Opera studies)

BACKGROUND

The efficacy of H2-receptor antagonists in functional dyspepsia is equivocal and the therapeutic place of proton pump inhibitors in functional dyspepsia is unknown.

AIM

To evaluate the efficacy of proton pump inhibitor therapy in functional dyspepsia.

METHODS

Patients (n = 1262) with a clinical diagnosis of functional dyspepsia (persistent or recurrent epigastric pain or discomfort for at least 1 month and a normal upper gastrointestinal endoscopy) were randomized to receive omeprazole 20 mg, 10 mg or identical placebo, for 4 weeks. Symptoms were assessed using validated measures. Helicobacter pylori status was determined pre-entry by a 13C-urea breath test.

RESULTS

On an intention-to-treat analysis (n=1248), complete symptom relief was observed in 38% on omeprazole 20 mg, compared with 36% on omeprazole 10 mg and 28% on placebo (P = 0.002 and 0.02, respectively). Among those with ulcer-like and reflux-like dyspepsia, complete symptom relief was achieved in 40% and 54% on omeprazole 20 mg, and 35% and 45% on omeprazole 10 mg, respectively, compared with 27% and 23% on placebo (all P < 0.05, except omeprazole 10 mg in ulcer-like dyspepsia, P = 0.08). There was no significant benefit of omeprazole over placebo in dysmotility-like dyspepsia. Symptom relief was similar in H. pylori-positive and negative cases.

CONCLUSIONS

Omeprazole is modestly superior to placebo in functional dyspepsia at standard (20 mg) and low doses (10 mg) but not in patients with dysmotility-like dyspepsia.

[The effect of theophylline preparations on morphine-induced spasm of Oddi's sphincter in man]

In this paper a short overview is given about pathophysiology of Oddi's sphincter function and diagnosis as well as pharmacological therapy of the hypertonic dyskinesia. According to the pharmacological background of muscle relaxation in other organs, theophyllin preparations: aminophyllin and retard theophyllin were used to inhibit spasm of Oddi's sphincter provoked by morphine in 9 patients with hypertonic dyskinesia of biliary and/or pancreatic outlet. The enzyme elevations (SGOT and/or amylase) and pain response to morphine significantly diminished in all but one patient during the evocative tests and the effect seemed to be dose-dependent until about 500 mg of theophyllin. The long acting theophyllin may be useful in hypertonic Oddi's sphincter dyskinesia mainly in combination with nitrates to prevent nitrate tolerance and intolerance and for treatment of "idiopathic" pancreatitis as well as "postcholecystectomy" syndrome. It might prevent papillary stenosis and adenomyosis which seem to be precancerous states of the papillary tumors.

[The role of jejunal feeding in the treatment of acute necrotizing pancreatitis and in recurrence of chronic pancreatitis with severe necrosis]

Acute necrotising is the most serious form of pancreatic inflammatory diseases leading to multiorgan failure and high (15-20%) mortality. The poor nutritional and metabolic condition of the patient and secondary bacterial translocation further rise the mortality. A recently introduced method of continuous nasojejunal feeding putting the pancreas into rest with basal pattern of secretion resulted in lower mortality rate by using adequate nutrition into the second loop of jejunum bypassing duodenopancreatic stimulations via an endoscopically placed feeding tube. The better nutritional and immunological states of the patients, the restored absorption and intestinal motility promote the recovery of pancreatitis, prevent bacterial translocation, resulting in time and in financial spares. Although surgery is occasionally inevitable because of progression of pancreatitis, nasojejunal feeding improves the general condition of patients more efficiently than parenteral nutrition and makes the scheduling of the operation optimal. The authors retrospectively analyse the results of treatment in 56 patients suffering from acute necrotising pancreatitis, as well as in 30 patients with chronic pancreatitis accompanied with more than 20% of necrosis in the pancreas and admitted to their gastroenterological medical department during 5 years. The effect of parenteral nutrition were less beneficial than that of jejunal feeding regarding the mortality and the necessity of operative interventions. Chronic pancreatitis with severe necrosis behaved similarly to the acute necrotising pancreatitis. The continuous nasojejunal feeding seems to be a promising new method for acute necrotising pancreatitis preventing complications and severe catabolic state of the disease by a cost--effective manner.

Effect of endotoxin administration on the severity of acute pancreatitis in two experimental models

CONCLUSIONS

Endotoxemia can transform acute pancreatitis (AP) into a more severe form of the disease in models of AP provoked by common pancreatico-biliary duct ligation or L-arginine injection.

BACKGROUND

It has been shown that systemic endotoxemia is a common feature in severe AP. The effect of endotoxemia on the course of experimental pancreatitis is unknown.

METHODS

AP was induced by common pancreatico-biliary duct ligation (experiment 1) and i.p. injection of 250 mg/100 g body wt of L-arginine (experiment 2). Test animals of both experiments received i.p. injections of 0.5 and 1.0 mg/100 g body wt of endotoxin at the induction of AP. Saline-treated and only endotoxin-dosed animals served as controls for both experiments. Mortality rates and pancreatic histology were investigated at 48 h.

RESULTS

The mortality rate was significantly elevated (60%, p < 0.05) in experiment 1 when 1.0 mg/100 g of endotoxin was given. In experiment 2, the mortality rate was also increased (30%) at this dose of endotoxin without reaching significance. Histologic changes were more severe in both groups of AP treated by the two doses of endotoxin than without it. Acinar necrosis and hemorrhage were highly elevated (p < 0.01) in both experiments when AP was combined with 1.0 mg/100 g body wt of endotoxin. The animals receiving only endotoxin showed only slight inflammatory and necrotic changes.

[Management of diabetes induced by nearly total (95%) pancreatectomy with autologous transplantation of Langerhans cells]

The present report concerns a patient who had undergone nearly total pancreatectomy (95%) with pancreatic islet autotransplantation for intractable pain caused by obstructive chronic pancreatitis. Islets were prepared by a modified collagenase digestion and were cultured in vitro in Eagel's medium in 5% CO2 in air at 37 degrees C for 5 days. The resultant preparation, containing about 150,000 islets, was injected into the recipient's liver via the umbilical vein. No complication occurred from the pancreatectomy or transplant. Postoperatively, the patient had complete relief of the abdominal pain, and the insulin-independent condition remained with normal fasting blood glucose, and hemoglobin A1c for 11 months. Subsequently the fasting hyperglycemia was evident, and the patient began oral antidiabetic medication, but 2 year after transplantation the insulin-dependent condition demanded exogenous insulin (24 U). At present the fasting serum C-peptide level is 0.6 ng/ml and the HbA1c of 5.8% confirms the normoglycemic condition at the same insulin dose. Islet auto-transplantation should be considered as an adjunct procedure to prevent or ameliorate diabetes after total or nearly total pancreatic resection.

[Tumors of the papilla of Vater--diagnostic and therapeutic dilemmas]

Benign and malignant tumors of papilla Vateri are rare diagnoses in the endoscopic practice. Sixteen patients with benign and 22 cases of malignant tumors are presented. In all of them endoscopic cholangiopancreatography with or without papillotomy followed by biopsy and operation in 13 cases was performed. Biopsy confirmed the endoscopy in 71%. Adenomyosis, supposed by endoscopy was proved by repeated histology in only 2/9 cases although invasive component of the tumor was found in 3/9 patients at operation underlying precancerous nature of this entity. Among 5 cases of villous adenoma one developed malignant alterations during 4 years of follow-up. Biopsy was not more effective after papillotomy than without it, and 5-7 days of delay for recovery of thermic lesion did not ameliorate success rate of histology. For malignant diseases surgical therapy should be considered if staging of tumor and general condition of the patient permits. In unresectable cases endoscopic palliation (papillotomy or polypectomy with or without drainage) can increase survival. In patients with benign tumors operative endoscopy followed by regular ultra-sonography and endoscopy seems to be necessary.

[Treatment of pancreatic insufficiency with a preparation containing high lipase activity]

In vitro testing of lipase survival of Panzytrat 25,000 homogenized in Tris HCl buffer and Lundh meal stimulated gastric or duodenal contents demonstrated favorable stability of lipase of this new preparation in the protein and fat containing gastric and duodenal juices of patients with chronic pancreatitis. Later an open, intra-individually controlled study with two doses of Panzytrat 25000 (5 x 1 and 5 x 2 capsules/day) was performed in 10 patients with severe pancreatic steatorrhoea. A diet containing 70 g of fat/day was offered and the 3-day fat loss of collected stools was measured in the last 3 days of 5-day equilibration periods with and without replacement therapy. After these short-term periods, patients were treated with 5 x 1 capsules of the drug for one month and body weight increases as well as patient's appraisals were registered. Stool weight and fat loss maximally decreased already in response to the 5-day treatment with 5 x 1 capsules of drug and double dose of the preparation did not further decrease steatorrhoea in most cases except 2 patient. Disappearance of fat loss was achieved in 3 out of ten patients. Body weight of patients increased in most cases and their subjective evaluation was also favorable.

[Experience with insertion of an endoscopic endoprosthesis in a case of inoperable bile duct calculi]

Endoscopic sphincterotomy for removal of stones from the common bile duct is an established procedure. Large stones, however, can be unavailable for basket trapping and/or extraction in some cases. In these patients, which are at high risk for surgery, endoscopic insertion of biliary endoprosthesis seems to be an alternative approach to dissolution therapy or ESWL. During the last 5 year, among 4081 ERCP-s 879 examinations demonstrated common bile duct (CBD) stones in our institutions. In 81 of these cases, an endoprosthesis was inserted into the CBD after extended endoscopic sphincterotomy because of failure of extraction of the large stones. Also ursodeoxycholic-acid treatment was initiated thereafter. Mean age of patients was 76 yrs (range 46-95 yrs), 51 females and 30 males. Acute complications after procedure were: mild bleeding not requiring transfusion, and 1 perforation treated surgically some days after prosthesis placement. Late complications until now included: peritonitis in 1 case, and recurrent jaundice due to drain clogging in 12 patients. These patient were treated with replacement of endoprosthesis. Remaining patients are well since the procedure and in 26 cases controlled about 17 months after endoprosthesis placement endoscopy verified significantly smaller or no stones in the common bile duct and in 4 cases even the endoprosthesis has disappeared.

CONCLUSION

endoscopic insertion of a biliary endoprosthesis is a safe and effective treatment for the huge CBD stones in high risk patients in whom endoscopic sphincterotomy and attempts to remove the stones are not successful. In more than 30% of cases dissolution of stones with ursodeoxycholic acid may be expected.

Biphasic effect of prostaglandin E1 on the severity of acute pancreatitis induced by a closed duodenal loop in rats

The effect of prostaglandin E1 (PGE1) on the severity of acute pancreatitis induced by a closed duodenal loop in the rat was tested. PGE1 was administered subcutaneously at various doses (3, 6, 12, and 24 microgram/kg) at hourly intervals, from the induction of acute pancreatitis up to the 24th hour. A saline-treated group served as the control. The mortality rate was recorded, and pancreatic histology was evaluated by a scoring system. Serum amylase activity and pancreatic amylase, trypsin, protein, and desoxyribonucleic acid (DNA) contents were determined at 24 h. Administration of PGE1 influenced the severity of acute pancreatitis biphasically. Serum amylase was reduced significantly (p < 0.01) at a dose of 12 microgram/kg/h, but less at 24 microgram/kg/h. Pancreatic weights did not differ in the groups. Pancreatic amylase, trypsin, and protein contents showed significant elevations (p < 0.01), yet the mortality rate was reduced using 6 and 12 microgram/kg/h doses of PGE1 compared to controls, but not at higher and lower doses. The DNA content was significantly higher at the 6 microgram/kg/h dose, compared to the control. The extent of necrosis and the severity of hemorrhage were reduced significantly (p < 0.05) at doses of 6 and 12 microgram/kg/h of PGE1, but less at 24 microgram/kg/h. Leukocyte infiltration was not affected. In conclusion, optimal doses of PGE1 can ameliorate, but higher doses increase, the severity of acute pancreatitis in this experimental model.

Excitatory amino acid antagonists attenuate the effects of cocaine on extracellular dopamine in the nucleus accumbens

The effect of N-methyl-D-aspartate and alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate/kainate excitatory amino acid antagonists on systemic cocaine-induced increases in extracellular dopamine was examined. The alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate/kainate receptor subtype antagonist, 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX), and N-methyl-D-aspartate receptor antagonists, 2-amino-5-phosphonovalerate and dizocilpine, were infused via a microdialysis probe placed in the nucleus accumbens. The local infusion of 2-amino-5-phosphonovalerate (500 microM), dizocilpine (50 microM) and CNQX (100 microM), started 80 min before cocaine injection, significantly inhibited the cocaine-induced increase in extracellular dopamine. The CNQX blockade was dose-dependent with respect to both CNQX concentration infused and dose of cocaine administered. Simultaneous infusion of the two antagonists (500 microM 2-amino-5-phosphonovalerate and 100 microM CNQX) did not lead to further reductions in the effects of cocaine when compared to either antagonist alone. Our results suggest that both N-methyl-Daspartate and alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate/kainate subtypes of excitatory amino acid antagonist receptors may contribute to the stimulatory effect of cocaine on extracellular dopamine in the nucleus accumbens.

[Annular pancreas in an adult]

Annular pancreas is a rare congenital anomaly which can remain symptom free for a long time and be manifested mainly in adults. 1130 endoscopic retrograde pancreatographies were performed in the author's laboratory during 3.5 years, and annular pancreas was seen in 2 cases. Duodenal obstruction with consecutive ulcers was the clinical manifestation in a young woman requiring duodeno-jejunostomy. Annular pancreas was an accidental finding in an other old woman presenting obstructive jaundice caused by several big stones in the main bile duct. A short review of the literature is given concerning the diagnostic possibilities, eventual complications and treatment modalities of this rare anomaly. It is emphasised that the diagnosis became possible due to the modern radiologic and endoscopic methods.

[Treatment of empyema of the gallbladder by endoscopic drainage]

Medical history of an old female patient is described. Gallstones were extracted from the main bile duct after endoscopic papillotomy when she was 83 ys old. Eighteen months later, she presented an obstruction of the cystic duct with a consecutive empyema of gallbladder. The obstruction was relieved mechanically by inserting a catheter through guide-wire in the cystic duct and moving the impacted stone into the gallbladder. A naso-cholecystic drain was placed and kept in the gallbladder for six days to assure free passage of bile and to administer local antibiotic treatment. The patient quickly recovered, she has not presented any repeated cholecystitis or cholangitis in the last year. It was pointed out, that the endoscopic access to the gallbladder became possible. This technique offers an alternative way in the treatment of patients with high operative risk.

Pancreatic trophism in experimental liver cirrhosis

Pancreatic trophism and pancreatic enzyme composition, and plasma levels of cholecystokinin, insulin, glucagon, and glucose in liver cirrhosis induced by chronic thioacetamide administration (0.02% in the drinking water for 12 mo) were studied in rats. Advanced liver cirrhosis was evident in all thioacetamide-treated rats. The weight of the pancreas and its contents of DNA, protein, trypsinogen, chymotrypsinogen, proelastase, secretory trypsin inhibitor, and amylase were significantly increased as compared to the controls. The pancreatic secretory enzyme content changes showed a nonparallelism, characteristic of a cholecystokinin effect. Light and electron microscopy revealed a normal pancreatic architecture. Bioassayed plasma cholecystokinin levels in both fed and 24-h-fasted cirrhotic rats were significantly higher than in the corresponding controls. The plasma glucose, insulin, and glucagon levels demonstrated hypoglycemic tendencies with a glucagon predominance. These findings indicate that advanced liver cirrhosis in the rat is accompanied by pancreatic hypertrophy and hyperplasia, which might be attributed, at least in part, to elevated circulating cholecystokinin levels.

[New trends in the treatment of exocrine pancreas deficiency]

Economic function of the exocrine pancreas is based on non-parallel synthesis, transport and secretion of pancreatic enzymes during basal state and postprandially. Reserve capacity of acinar cells is also augmented by adaptation to the diet as well as by regeneration. In mild pancreatic insufficiency complex dietetic considerations help to maintain the necessary secretory capacity of the pancreas. In severe cases effective substitution therapy is mandatory and increasing lipase survival by dietetic maneuvers, by optimizing trypsin and chymotrypsin levels as well as acid and bile secretion can significantly ameliorate results of replacement therapy of steatorrhea. However, in painful chronic pancreatitis high protease activities seem to be beneficial. Individual replacement therapy with pancreatin preparations adapted to the requirements of the patient has to be chosen in difficult cases.

Possible role of Coxsackie-B virus infection in pancreatitis

Coxsackie-B antibodies were examined in a study of 118 patients with acute and relapsing chronic pancreatitis. The rise in antibody titers was significant in 40 cases. Fourteen had acute, five relapsing acute, and 21 chronic pancreatitis. Among patients with acute pancreatitis, we detected infectious hepatitis in six cases. Two patients with persisting acute pancreatitis received levamisole as an immune adjuvant, which promoted their recovery. It seems that Coxsackie-B virus can cause acute pancreatitis, and it can also worsen chronic pancreatitis.

Influence of bile on the severity of acute experimental pancreatitis induced by closed duodenal loop in rat

The study was performed to assess the ethiological role of bile in acute pancreatitis provoked by closed duodenal loop in rat. In group I a closed duodenal loop was created by method of Nevalainen. A similar operation was performed in group II, but the common pancreatico-biliary duct was ligated just under the liver. In the control group (group C) only the mobilization of duodenum was performed. After 24 hours the mortality rate was 20% in group I, but 0% in group II and C. The amount of ascitic fluid showed significant elevation in group I versus II and group C, and in group II as compared to group C, too. The serum amylase was significantly higher in group I than group II and group C, and in group II was also higher as compared to group C. Serum total protein differed significantly between all groups, while albumin and total calcium were significantly lower in group I than group II, but group II was only slightly reduced versus group C. Histology showed no differences between groups I and II, but both differed significantly from group C. In conclusion bile seems to be an aggressive factor in pathogenesis of acute pancreatitis induced by closed duodenal loop in rat, but other factors may play more important roles.