English language version of the S3-consensus guidelines on chronic pancreatitis: Definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis

Chronic pancreatitis is a disease of the pancreas in which recurrent inflammatory episodes result in replacement of pancreatic parenchyma by fibrous connective tissue. This fibrotic reorganization of the pancreas leads to a progressive exocrine and endocrine pancreatic insufficiency. In addition, characteristic complications arise, such as pseudocysts, pancreatic duct obstructions, duodenal obstruction, vascular complications, obstruction of the bile ducts, malnutrition and pain syndrome. Pain presents as the main symptom of patients with chronic pancreatitis. Chronic pancreatitis is a risk factor for pancreatic carcinoma. Chronic pancreatitis significantly reduces the quality of life and the life expectancy of affected patients. These guidelines were researched and compiled by 74 representatives from 11 learned societies and their intention is to serve evidence-based professional training as well as continuing education. On this basis they shall improve the medical care of affected patients in both the inpatient and outpatient sector. Chronic pancreatitis requires an adequate diagnostic workup and systematic management, given its severity, frequency, chronicity, and negative impact on the quality of life and life expectancy.

[How safe is sedation in gastrointestinal endoscopy? A multicentre analysis of 388,404 endoscopies and analysis of data from prospective registries of complications managed by members of the Working Group of Leading Hospital Gastroenterologists (ALGK)]

BACKGROUND

Gastrointestinal endoscopies are increasingly being carried out with sedation. All of the drugs used for sedation are associated with a certain risk of complications. Data currently available on sedation-associated morbidity and mortality rates are limited and in most cases have substantial methodological limitations. The aim of this study was to record severe sedation-associated complications in a large number of gastrointestinal endoscopies.

METHODS

Data on severe sedation-associated complications were collected on a multicentre basis from prospectively recorded registries of complications in the participating hospitals (median documentation period 27 months, range 9 - 129 months).

RESULTS

Data for 388,404 endoscopies from 15 departments were included in the study. Severe sedation-associated complications occurred in 57 patients (0.01 %). Forty-one percent of the complications and 50 % of all complications with a fatal outcome (10/20 patients) occurred during emergency endoscopies. In addition, it was found that 95 % of the complications and 100 % of all fatal complications affected patients in ASA class ≥ 3.

CONCLUSIONS

Including nearly 400,000 endoscopies, this study represents the largest prospective, multicenter record of the complications of sedation worldwide. The analysis shows that sedation is carried out safely in gastrointestinal endoscopy. The morbidity and mortality rates are much lower than previously reported in the literature in similar groups of patients. Risk factors for the occurrence of serious complications include emergency examinations and patients in ASA class ≥ 3.

[Chronic abdominal pain--internistic-psychosomatic aspects]

Abdominal pain is considered to be chronic when it persists for at least three months or when a patient experiences such pain for a total of three months during the course of a year. Pathophysiologically, nociceptive/neuropathic functional pain syndrome, mental disorders with the cardinal symptom of chronic pain, and mixed forms can be distinguished. In 50% of the patients, the cause of chronic abdominal pain is a functional gastrointestinal disorder e.g. functional dyspepsia irritable bowel syndrome. On the basis of a structured pain history, a physical examination and a basic "technical" diagnostic program (laboratory investigations, abdominal ultrasonography, Esophagogastroduodenoscopy, colonoscopy), correct assignment to one of the above-mentioned can be achieved in most of the cases.

[Requirements and recommendations for performing endosonographies]

For improvement of quality the working group of the Society of Gastroenterology in Nordrhein-Westfalen (Germany) was engaged with the questions, which apparative, personal and training conditions for endoscopic ultrasound are useful. The following proposals were preliminarily presented at the annual Congress of the DGVS (German Society of Digestive and Metabolic Diseases) 2001. They are thought to be subject of discussion for guidelines to be elaborated by this national society.

[Endoscopic ultrasonography (EUS) of the upper gastrointestinal tract - prospective multicenter study to evaluate time and staff requirements]

BACKGROUND AND AIMS

Endoscopic ultrasonography is an important procedure in the diagnostic work-up of gastrointestinal and mediastinal masses. To evaluate the time and staff requirements for the examination, a prospective multicenter study was carried out.

METHODS

27 centers were asked to document their endoscopic ultrasonographic procedures over a 4-month period, using a standardized protocol comprising several parameters: time and staff requirements (overall and related to organs), time spent on informing the patients, preparation, performance and monitoring of the examination and subsequent care of patient as well as of endoscopic equipment.

RESULTS

484 examinations from 11 centers were suitable for evaluation, 25 % of the patients were out-patients. Median examination time was 20 minutes (range: 5 - 60 min) without significant differences concerning the device but with greater differences concerning the different organs (pancreas 23.5 minutes, esophagus 15 minutes). Median time of subsequent care was 35 minutes in out-patients, 25 minutes in hospitalized patients, with a great variety between different centers. In 70 % of examinations one doctor and one nurse were involved. For sedation midazolam was used in 90 % of cases, pethidin for analgesia in 30 % of cases.

CONCLUSIONS

The obvious time and staff requirements for endoscopic ultrasonography are comparable to historical data for the performance of a colonoscopy. In out-patients the time required seems to be higher.

Persistently altered visceral perception after resection of an esophageal granular cell myoblastoma: a therapeutic concept revisited

Granular cell tumors (GCTs) are rare and usually benign gastrointestinal tumors. Their most frequent symptoms are dysphagia and epigastric or retrosternal discomfort. We here report a case of esophageal GCT with continued symptoms of retrosternal discomfort, postprandial feeling of fullness, and early satiety despite complete thoracoscopic resection of the tumor. In contrast, all functional tests were in the normal range. We thus suggest that, due to their neuroectodermal origin, GCTs may affect neuronal alterations leading to a persistently disturbed visceral mechanosensory perception. Consequently, this case also cautions the therapeutic concept to solely relieve GCT symptoms by resection if the tumor is less than 20 mm in diameter.

Pancreatic intraductal ultrasonography (IDUS) allows early diagnosis of pancreatic carcinoma in situ: a case report

A 66-year-old woman was admitted with diarrhea, weight loss, slight recurrent abdominal pain, and raised serum amylase and lipase. Lactose intolerance was diagnosed, and treatment was begun. The symptoms diminished. However, slight back pain and elevated serum amylase and lipase levels persisted. A pancreatic tumor was then suspected. Ultrasound, spiral computed tomography (CT), magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography (MRCP) examinations were inconclusive. Endoscopic retrograde cholangiopancreatography (ERCP) showed a slight narrowing of the pancreatic duct within the pancreatic body, and endoscopic ultrasound (EUS) revealed a 10 mm intrapancreatic lesion. Finally, intraductal ultrasonography (IDUS) reliably identified a small pancreatic tumor. The tumor was resected, and histology confirmed a well-differentiated adenocarcinoma in situ (UICC stage 0, TisN0M0). This case shows that using high-resolution imaging techniques such as EUS plus IDUS, small malignant pancreatic lesions can be detected at an early stage, when curative action is possible.

Fire eater's risk: lipoid pneumonia following aspiration of a liquid hydrocarbon mixture

Acute aspiration of a liquid hydrocarbon mixture by fire eaters may cause severe lipoid pneumonia. The toxic effect of ingested hydrocarbon chains depends on their length and biophysical qualities. We report the case of a patient who accidentally aspirated a hydrocarbon liquid resulting in a lipoid pneumonia. The pathomechanism, diagnostic work-up, and the therapeutic approach are discussed.

[Gastrocolic fistula - a rare cause of cachexia and polyneuropathy]

Gastrocolic fistula is a rare clinical disorder which in the past most often occurred after gastric surgery or carcinoma of the gastrointestinal tract. However, during the last decade an increasing number of cases after benign gastric ulcers have been described. Most common symptoms have been weight loss, abdominal pain, diarrhea and copremesis. A 49-year-old cachectic patient presented with a 2-year history of abdominal discomfort and diarrhea. He reported a weight loss of 32 kg during this period and was finally unable to move because of exhaustion. Furthermore, he suffered of burning paresthesia of the legs and the abdomen. His medical history included a Billroth II operation because of recurrent ulcer disease in 1987. Barium enema revealed a gastrocolic fistula which caused small bowel bacterial overgrowth with villous atrophy and malabsorption and development of polyneuropathy. The fistula was surgically resected, and postoperatively, the patient improved and regained his weight. Gastrocolic fistula is a rare cause of diarrhea and should be considered in clinical practice. Barium enema is superior to endoscopy in detecting gastrocolic fistula.

[Autoimmune pancreatitis]

Over the last years several case reports and articles have been published suggesting that a new form of chronic pancreatitis has been diagnosed and named autoimmune pancreatitis. The present overview scrutinizes the proposed evidence in the light of the current literature and aims to prove whether autoimmune pancreatitis is a special entity of chronic pancreatitis.

[Generalized pustulous psoriasis: A novel extraintestinal manifestation of Crohn's disease?]

A 66-year-old female patient suffering for 10 years from Crohn's disease firstly presented with a parallel outbreak of generalized pustulous psoriasis and Crohn's disease. A second synchronous exacerbation of both disorders occurred after discontinuation of treatment with prednisolone, methotrexate, and mesalazine. As to their pathogenetic concepts, both disease entities reveal similar immunologic alterations, i. e. comparable patterns of cytokines, chemokines, and inflammatory cells (T cells and neutrophils). Generalized pustulous psoriasis, therefore, might develop as hitherto undescribed, more rare extraintestinal manifestation of Crohn's disease.

Campylobacter jejuni-induced severe colitis--a rare cause of toxic megacolon

The development of toxic megacolon as a sequel of infectious colitis is rare. We have observed the very rare case of a campylobacter jejuni-induced toxic megacolon. A 28-year-old man was admitted with severe enterocolitis and appearance of blood in stools. He had been treated with loperamide without success. Two days after admission stool cultures revealed campylobacter jejuni and then an oral antibiotic therapy was started. On the fifth day clinical performance deteriorated again with development of toxic megacolon and consecutive subtotal colectomy. Rectoscopy before discharge after 13 days showed a normal mucosa. The unusual course with first improvement and then rapid deterioration despite adequate therapy was observed in 4 other cases, which may also be a hint of ensuing megacolon. Even in usually harmless enterocolitis like campylobacter infection, predisposing factors such as loperamide are known to precipitate toxic megacolon and should be considered in clinical practice.

[Familial Mediterranean fever. New aspects with respect to molecular genetics and pathogenesis revealed in three case reports]

HISTORY AND CLINICAL PRESENTATION

Three young Turkish males were admitted because of acute abdominal pain and fever. All 3 patients had recurrent attacks of these symptoms every few weeks since years with each attack lasting 2 to 3 days. One patient developed a renal amyloidosis with an end-stage renal failure.

DIAGNOSTICS AND CLINICAL COURSE

All patients presented with local abdominal tenderness and an elevation of inflammatory parameters (WBC, ESR, CRP and fibrinogen). X-ray studies, ultrasound and upper endoscopy were normal. In 1 patient histology yielded amyloid fibrils in the antrum of the stomach. In a molecular genetic analysis 2 patients were compound heterozygous for 2 common mutations of the gene responsible for the familial Mediterranean fever (FMF). In all patients the symptoms vanished spontaneously according to an acute attack of FMF. After symptomatic treatment a prophylaxis with colchicine was started.

CONCLUSION

Cloning of the FMF gene and its mutations and identification of the gene product "pyrin" reveals new aspects on genetics and pathophysiology. The improved diagnostic procedure enables an early start of colchicine treatment, especially to prevent renal amyloidosis.

Nonsurgical management of acute pancreatitis. Use of antibiotics

In severe AP, infected necrosis is the leading cause of death. Prevention of pancreatic infection is the major goal in the treatment of patients with necrotizing pancreatitis. Adequate early antibiotic therapy seems to be promising in these patients. Their role and the optimal timing of the antibiotic therapy (e.g., benefit of prophylactic application) are discussed. Preliminary results of a study in patients with infected pancreatic necrosis and exclusively or primarily conservative treatment also are presented.

Diagnostic dilemma in pancreatic lymphoma. Case report and review

Non-Hodgkin's lymphoma predominantly involving the pancreas is a rare tumor of the gastrointestinal tract. Diagnosis can be difficult, since lymphoma may mimic carcinoma or pancreatitis. Lymphoproliferative diseases induced by immunosuppressive therapy frequently occur in the gastrointestinal tract of posttransplant patients. However, pancreatic involvement of posttransplant lymphoma is an exceptional condition. We present the case of a cyclosporin-treated renal transplant recipient with pancreatic lymphoma mimicking carcinomatous or inflammatory tumors. The diagnostic difficulties and treatment options of pancreatic lymphoma as well as lymphoproliferative disorders in immunosuppressed renal recipients are discussed in light of the current literature.

[Etiology, pathogenesis and pathophysiology of acute pancreatitis]

The etiology of acute pancreatitis is based on several causes, among which idiopathic nature (< 30%) is second to biliary stone disease (60-70%). It is still under debate whether alcohol as the main cause of chronic pancreatitic disease can cause acute pancreatitis. Based on Opie's "obstruction theory" of 1901 and experimental data, it is now widely accepted that the gallstone passage into or through the terminal biliopancreatic ductal system triggers acute (necrotizing) pancreatitis by causing pancreatic ductal obstruction. However, the sequential intracellular mechanisms in the pathogenesis of acute pancreatitis remain unclear. A co-localization hypothesis has been proposed to explain the premature intracellular activation of trypsinogen to trypsin: due to a yet unknown defect in the intracellular protein transport and sorting system within the acinar cell, lysosomal hydrolases (i.e. cathepsin B) and secretory proteins (i.e. trypsinogen) co-localize in a fragile postgolgi vacuole where activation can occur. In addition, alterations of exo- and endocytosis at the apical pole exist (i.e. secretion block). The pathophysiological events are characterized by local and systemic hypovolemia and (micro)circulatory failure aggravating necrosis, followed by ARDS, renal failure and several other severe complications (i.e. sepsis and DIC). The systemic overflow of proteolytic enzymes (i.e. PLA-2) and kinins plays a major role as mediating factor in severe cases, resulting in multiorgan failure.

[Clinical aspects and classification of acute pancreatitis]

Clinically acute pancreatitis is characterized by severe abdominal pain and systemic symptoms, such as nausea, vomiting and circulatory shock. In most cases the diagnosis is verified, and differential diagnoses are excluded, by elevated serum enzyme activities as well as characteristic findings in imaging procedures. The mild form of acute pancreatitis (about 80%) is characterized by an uncomplicated course and recovery within 72 hours in response to adequate therapy. By contrast, severe pancreatitis (about 20%) shows formation of necroses and a protracted course which frequently is dominated by development of systemic complications with subsequent failure of individual or several organ systems. On this background, early discrimination between mild and severe pancreatitis is important for therapeutic management and assessment of prognosis. Several classifications have been suggested in recent years but their use has been limited because they partly depend on complicated multiscoring systems. On the other hand, it has been possible to establish simple severity markers such as serum CRP and PMN-elastase that correlate well with further clinical course and outcome.

Duodenal and ileal nutrient deliveries regulate human intestinal motor and pancreatic responses to a meal

It is assumed that in humans pancreatic and gastrointestinal motor responses to a meal are coordinated and regulated mainly by duodenal nutrient exposure. On the other hand, there is evidence that the distal intestine may participate in the regulation of gastrointestinal functions. The aim of this study was to compare human pancreatic and intestinal motility responses to a meal and to correlate them with nutrient exposure of the proximal and distal intestine. After intubation with an oroileal multilumen tube for marker perfusion, duodenal and ileal aspiration, and intestinal manometry, 14 healthy subjects received a mixed test meal (1,257 kJ). Intraluminal nutrient concentrations, enzyme activities, and small intestinal motility were analyzed for 6 h postprandially. Duration of duodenal nutrient exposure was 3.4 +/- 0.2 h, and duration of pancreatic enzyme response and fed motor pattern was 2.5 +/- 0.2 and 3.5 +/- 0.3 h, respectively. Durations of pancreatic secretory and motor responses were correlated (P < 0.05), but neither duration of digestive secretory nor of motor activity correlated with that of prandial duodenal nutrient concentrations. By contrast, they were associated with the relative increase in ileal nutrient delivery late postprandially (P < 0.05). Physiological late postprandial delivery of nutrients to distal intestinal sites is correlated with the termination of digestive pancreatic and motor responses and may participate in their control.

A cholecystokinin-releasing factor mediates ethanol-induced stimulation of rat pancreatic secretion

The mechanisms by which short-term ethanol administration alters pancreatic exocrine function are unknown. We have evaluated the effects of ethanol administration on pancreatic secretion of digestive enzymes. In our studies, anesthetized as well as conscious rats were given ethanol at a rate sufficient to cause the blood ethanol concentration to reach levels associated with clinical intoxication. Ethanol was administered over a 2-h period during which blood ethanol levels remained stably elevated. We report that intravenous administration of ethanol results in a transient increase in pancreatic amylase output and plasma cholecystokinin (CCK) levels. The ethanol-induced increase in amylase output can be completely inhibited by the CCK-A receptor antagonist L-364,718 and partially inhibited by the muscarinic cholinergic antagonist atropine. The ethanol-induced rise in amylase output can be completely prevented by instillation of trypsin into the duodenum or by lavage of the duodenum with saline during ethanol administration. Furthermore, the intraduodenal activity of a CCK-releasing factor is increased by infusion of ethanol. These studies indicate that administration of ethanol causes rat pancreatic exocrine secretion to increase. This phenomenon is mediated by a trypsin-sensitive CCK-releasing factor which is present within the duodenal lumen. These observations lead us to speculate that repeated CCK-mediated ethanol-induced stimulation of pancreatic digestive enzyme secretion may play a role in the events which link ethanol abuse to the development of pancreatic injury.

Drug-associated pancreatitis: facts and fiction

In the past, numerous reports on drugs probably causing acute pancreatitis have been published. However, most of these case reports were anecdotal with a lack of obvious evidence and did not present a comprehensive summary. Although drug-associated pancreatitis is rare, it is gaining increasing importance with the introduction of several potent new agents, i.e., anti-acquired immunodeficiency syndrome drugs. The following comprehensive review scrutinizes the evidence present in the world literature on drugs associated with acute or chronic pancreatitis and, based on this, categorizes in a definite, probable, or possible causality. In addition, explanations for the pathophysiological mechanisms are discussed.

[Trimethoprim-sulfamethoxazole-induced cholestatic hepatitis. Clinico-immunological demonstration of its allergic origin]

HISTORY AND CLINICAL FINDINGS

A 22-year-old woman was given trimethoprim plus sulphamethoxazole for a urinary infection (160 and 800 mg, respectively, daily), drugs she had not previously taken. After 2 weeks she noticed a rash of small spots on her trunk. In addition she had nausea and vomiting. The rash faded within 2 days of stopping the drug, but progressive jaundice developed.

INVESTIGATIONS

SGPT and SGOT concentrations rose to maximally 328 and 83 U/l, total bilirubin to maximally 5.9 mg/dl. There was no evidence for viral hepatitis (B or C, cytomegalovirus, Epstein-Barr), autoimmune hepatitis or primary biliary hepatitis. Liver biopsy showed central acinar cholestasis, which suggested drug-induced liver damage.

COURSE

The patient's symptoms regressed over several weeks without any specific treatment and 8 weeks after onset of the rash the laboratory tests also became normal. The allergic cause of the cholestatic hepatitis was confirmed by a lymphocyte transformation test.

CONCLUSION

Clinical suspicion of drug allergy as cause of a cholestatic hepatitis can be confirmed reliably and without any risk to the patient with the lymphocyte transformation test.

Biochemical and morphological changes that characterise recovery from necrotising biliary pancreatitis in the opossum

The events that characterise recovery from severe biliary pancreatitis have not been defined. This study used a reversible model of necrotising pancreatitis, induced by obstructing the opossum common bile pancreatic duct (CBPD), to evaluate this phenomenon. The CBPD of opossums was obstructed with a balloon tipped catheter for five days and then decompressed by removal of the catheter. Recovery was evaluated 0-90 days after relief of obstruction. Serum bilirubin and amylase values rapidly declined, reaching control values 7-14 days after removal of the obstructing catheter. Pancreatic protein and amylase values were transiently increased shortly after relief of obstruction but returned to control values 21 days after decompression. Pancreatic ornithine decarboxylase activity and incorporation of [3H]-thymidine into DNA were transiently increased 14 days after duct decompression suggesting that regeneration occurs at approximately that time. Foci of pancreatic necrosis involved roughly 40% of the gland at time of decompression but these foci gradually disappeared and the gland resembled that of control animals 60 days after decompression. Evidence of fibrosis or collagen deposition in the pancreas was not noted at any time. These studies show that recovery after necrotising biliary pancreatitis occurs comparatively rapidly and the restitution ad integrum occurs. Recovery from necrotising acute pancreatitis in this model is not associated with the development of chronic pancreatitis.

Endocrine and exocrine pancreatic function after camostate-induced growth of the organ

It is well known that oral administration of camostate induces hyperplasia and hypertrophy of the rat pancreas. It is not clear, however, whether pancreatic hormone and enzyme secretion are affected by camostate treatment. In rats, daily administration of 200 mg camostate/kg b. wt for 14 days significantly increased pancreatic weight and pancreatic content of DNA, protein, amylase, lipase, trypsin and chymotrypsin, as well as the amount of insulin, glucagon and somatostatin. In the intact animal, blood glucose levels and serum concentrations of insulin and glucagon in response to an oral glucose load were not impaired after camostate treatment. In the isolated perfused pancreas, however, insulin and glucagon secretions were reduced, whereas somatostatin release was not affected. The volume of pancreatic juice produced by the unstimulated isolated perfused organ, as well as protein and enzyme secretion, were increased after camostate treatment. Likewise, the isolated perfused pancreas from camostate-treated rats secreted a larger volume of pancreatic juice and more protein in response to cholecystokinin (CCK), while enzyme secretion was affected in a non-parallel manner: amylase release was markedly reduced, lipase release was unchanged, and release of trypsin and chymotrypsin was increased.

Evaluation of necrotizing pancreatitis in the opossum by dynamic contrast-enhanced computed tomography: correlation between radiographic and morphologic changes

BACKGROUND

The ability to quantitate the extent of acinar cell necrosis with contrast-enhanced computed tomography (CT) during acute pancreatitis is uncertain.

STUDY DESIGN

Acute hemorrhagic necrotizing pancreatitis was induced in opossums by obstructing their biliopancreatic duct for up to seven days or by retrograde injection of a bile-trypsin taurocholate mixture into the opossum pancreatic duct. At selected times, groups of three animals each were examined by dynamic contrast-enhanced CT, and the abnormalities on the images were quantitated. Immediately following CT, the animals were sacrificed and the extent of necrosis was quantitated by morphometric analysis of tissue samples at the light microscope level.

RESULTS

The CT severity score as well as the degree of nonenhancement on dynamic contrast-enhanced CT were both closely correlated with the extent of acinar cell necrosis (r = 0.91 and r = 0.97, respectively).

CONCLUSIONS

The degree of pancreatic nonenhancement on dynamic contrast-enhanced CT can be used to quantitate the extent of pancreatic necrosis during acute necrotizing pancreatitis.

Luminal endocytosis and intracellular targeting by acinar cells during early biliary pancreatitis in the opossum

Cell necrosis in acute experimental pancreatitis is preceded by a redistribution of digestive enzymes into a lysosomal subcellular compartment. We have investigated whether endocytosis from the acinar cell lumen might contribute to this disturbance of intracellular compartmentation. In an animal model of pancreatitis involving pancreatic bile duct ligation in opossums, we have studied in vivo endocytosis of dextran 40 and [14C]dextran 70, cationized ferritin, and horseradish peroxidase from the apical surface of acinar cells before the onset of necrosis. Marker solutions were instilled into the pancreatic duct of anesthetized animals at physiological pressure. Tissue samples obtained at intervals of up to 60 min after instillation of markers were studied by electron microscopy and electron microscope autoradiography. All markers were taken up by acinar cells in control animals and in animals with obstructed pancreatic bile ducts. Markers for membrane-mediated endocytosis (cationated ferritin and horseradish peroxidase) were transported to lysosomes in both groups. In contrast, the fluid-phase tracer dextran was transported to the secretory pathway in controls but to lysosomes after duct ligation. Since dextran and luminally present secretory proteins can be expected to follow the same route after endocytosis, our findings suggest that altered intracellular targeting of endocytosed proteases might be one mechanism by which digestive zymogens reach an intracellular compartment in which premature activation can occur. This phenomenon may be a critical and early event in the pathogenesis of biliary pancreatitis.

Inositol trisphosphate-independent agonist-stimulated calcium influx in rat pancreatic acinar cells

CCK-JMV-180 is a cholecystokinin analog that stimulates digestive enzyme secretion from pancreatic acinar cells but does not cause either generation of inositol 1,4,5-trisphosphate or depletion of the inositol 1,4,5-trisphosphate-sensitive intracellular Ca2+ storage pool. We report that CCK-JMV-180 can accelerate Ca2+ influx into fura-2-loaded dispersed rat pancreatic acini and single acinar cells. Furthermore, CCK-JMV-180 accelerates Ca2+ influx into cells microinjected with the inositol 1,4,5-trisphosphate receptor antagonist heparin and into acini loaded with the Ca(2+)-chelating agent BAPTA (1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid). These results indicate that agonist-stimulated Ca2+ influx can occur (a) without depletion of the inositol 1,4,5-trisphosphate-sensitive intracellular Ca2+ storage pool, (b) without a rise in cytoplasmic free Ca2+ concentrations, and (c) after blockade of inositol 1,4,5-trisphosphate receptors. They suggest that depletion of an inositol 1,4,5-trisphosphate-independent intracellular Ca2+ storage pool and/or generation of a non-inositol 1,4,5-trisphosphate second messenger by CCK-JMV-180 may be a sufficient signal for acceleration of Ca2+ influx into rat pancreatic acinar cells.

Endogenous somatostatin possibly controls pancreatic growth: further evidence for feedback regulation

Specific inhibitors acting upon pancreatic proteinases in the gut can cause pancreatic hypertrophy ('growth'), which is probably mediated through a feedback mechanism utilizing cholecystokinin. We have proposed the involvement of somatostatin, and here test the hypothesis that endogenous somatostatin secreted into pancreatic juice may regulate pancreatic growth. Groups of rats were given the proteinase inhibitor camostate intragastrically for either 3, 7, 14, 28, or 56 days, when they were sacrificed. In some groups the pancreata were weighed and homogenized while in other groups isolated perfused pancreatic organ preparations were performed. Somatostatin was measured in the homogenates, pancreatic juice and portal vein effluents. In camostate-fed animals, pancreatic weights increased to a maximum at 28 days, while pancreatic somatostatin content increased significantly from the third day onwards, and somatostatin secretion into pancreatic juice increased progressively until day 28. In contrast, somatostatin secretion into portal blood remained unchanged from those of untreated controls over the duration of the experiment, and its concentration was lower than in pancreatic juice. These observations provide further evidence that endogenous pancreatic somatostatin may control pancreatic growth in rats.

Early ductal decompression prevents the progression of biliary pancreatitis: an experimental study in the opossum

BACKGROUND

The value of early endoscopic or surgical interventions to remove bile duct stones and decompress the biliopancreatic ductal system in gallstone pancreatitis is controversial.

METHODS

To evaluate this issue, acute hemorrhagic necrotizing pancreatitis was induced in opossums by obstructing the biliopancreatic ductal system with a balloon catheter for 1, 3, or 5 days.

RESULTS

A progressive increase in the severity of pancreatitis, as manifested by inflammation, fat necrosis, hemorrhage, acinar cell vacuolization, in vitro lactate dehydrogenase release, and acinar cell necrosis, was noted in these obstructed animals. In contrast, decompression of the obstructed ductal system by removal of the balloon catheter after 1 or 3 days prevented the increase in severity of these parameters of pancreatic injury.

CONCLUSIONS

We concluded that the severity of biliary pancreatitis in this model is dependent upon the duration of ductal obstruction and that decompression of the ductal system can prevent progression of the disease. These observations support the practice of early attempts to remove obstructing stones in clinical gallstone pancreatitis.

Pancreastatin--a mediator in the islet-acinar axis?

Pancreastatin was isolated from porcine pancreas in 1986 and has been shown to inhibit insulin release and exocrine pancreatic secretion in vivo. In the isolated perfused rat pancreas, we investigated its effect on the exocrine pancreas and evaluated its indirect effects mediated via the islet-acinar axis. In the presence of 16.7 mmol/L glucose, 20 pmol/L, 200 pmol/L, and 2 nmol/L pancreastatin reduced insulin release but did not affect exocrine pancreatic secretion stimulated by cholecystokinin (CCK), secretin, or bombesin. Pancreastatin also failed to affect unstimulated exocrine pancreatic secretion. In the presence of 1.7 mmol/L glucose, 200 pmol/L and 2 nmol/L pancreastatin inhibited glucagon release and potentiated CCK-stimulated exocrine pancreatic secretion. Inhibition of glucagon release and augmentation of exocrine pancreatic secretion may be independent phenomena, but they could be linked by the islet-acinar axis. Thus we speculate that a pancreastatin-induced inhibition of glucagon release may indirectly have caused augmentation of exocrine pancreatic secretion.

Pancreatic duct obstruction triggers acute necrotizing pancreatitis in the opossum

BACKGROUND

The common channel theory suggests that bile reflux, through a common biliopancreatic channel, triggers acute pancreatitis. In the present study, this controversial issue was evaluated using an experimental model of hemorrhagic necrotizing pancreatitis.

METHODS

American opossums underwent ligation of the pancreatic duct alone, bile and pancreatic duct separately, or common biliopancreatic duct; the severity of pancreatitis was evaluated at selected times after ligation.

RESULTS

Animals in all three experimental groups developed hemorrhagic necrotizing pancreatitis; the severity of pancreatitis was similar in each group, although only those subjected to common biliopancreatic duct ligation experienced bile reflux.

CONCLUSIONS

Bile reflux into the pancreatic duct, via a common biliopancreatic channel, is not necessary for the development of pancreatitis and does not worsen the severity of pancreatitis associated with pancreatic duct obstruction in this model.

Effect of cysteamine on insulin release and exocrine pancreatic secretion in vitro

Cysteamine is known to deplete somatostatin from pancreatic D cells. In the isolated perfused rat pancreas we investigated its effects on somatostatin and insulin release as well as exocrine pancreatic secretion in the presence of 16.7 mM glucose and 180 pM CCK-8. At a concentration of 0.1 mM, cysteamine had no significant effect on pancreatic endocrine and exocrine functions. At 10 mM, however, cysteamine released somatostatin (380 +/- 70 vs 100 +/- 20 fmol/20 min), inhibited insulin output (890 +/- 120 vs 13210 +/- 3260 mu units/20 min) and reduced exocrine pancreatic secretion (volume: 12 +/- 2 vs 20 +/- 2 microliters/20 min; lipase: 31 +/- 3 vs 60 +/- 7 units/20 min). We conclude that the complex changes induced by cysteamine are consistent with a physiological role of endogenous somatostatin in the regulation of insulin release. The reduction of exocrine pancreatic secretion, however, was at least in part, if not completely, mediated via the insuloacinar axis rather than a direct effect of cysteamine-released somatostatin on pancreatic acinar cells.

Importance of endogenous prostaglandins for the toxicity of cyclosporin A to rat endocrine and exocrine pancreas?

Previous work has shown that cyclosporin A is toxic to the endocrine and exocrine pancreas. The aim of this study was to examine whether endogenous eicosanoids play a role in controlling cyclosporin A induced toxicity. Rats were treated for eight days with indomethacin (2 mg/kg, twice daily) in addition to cyclosporin A (5 or 10 mg/kg daily). Effects of drug treatments on exocrine (as assessed by amylase and protein secretion into the pancreatic juice) and endocrine (as assessed by the glucose dependent insulin release) pancreatic functions, and pancreatic formation of prostaglandins and thromboxane were evaluated. Treatment with cyclosporin A in the doses used did not inhibit eicosanoid formation by the pancreatic tissue ex vivo. Indomethacin caused significant inhibition of pancreatic formation of prostaglandin E2, 6k prostaglandin F1 alpha and thromboxane B2. Combined treatment with indomethacin and cyclosporin A (5 or 10 mg/kg) augmented cyclosporin A induced pancreatic toxicity with further impairment of insulin release, amylase secretion, and pancreatic juice protein content, but did not result in more pronounced inhibition of pancreatic eicosanoid formation. The increased toxicity of the combined treatment was, however, associated with raised cyclosporin A whole blood concentrations. The data suggest that the potentiation of pancreatic toxicity of cyclosporin A observed during coadministration of indomethacin is not the result of suppression of endogenous pancreatic eicosanoid biosynthesis, but more likely results from altered cyclosporin A pharmacokinetic which may be caused by an interference of indomethacin with the hepatic cytochrome P-450 dependent monooxygenase involved in cyclosporin A metabolism. The possibility that coadministration of non-steroidal antiinflammatory drugs aggravates toxic effects in cyclosporin A treated patients should be considered.

Stimulatory and inhibitory effects of galanin on exocrine and endocrine rat pancreas

The influence of the neuropeptide galanin, present in intrapancreatic nerve endings, on the endocrine pancreas is well known. The most potent effect of galanin is inhibition of insulin release. Little is known of its effect on the exocrine pancreas. Whether galanin plays a role in the regulation of exocrine pancreatic secretion and whether this effect is mediated directly on acinar cells or indirectly via the influence on insulin secretion is not clear. In the present study, we investigated these questions using the model of the isolated and arterially perfused rat pancreas with intact exocrine and endocrine secretion. In the presence of 15.8 mM glucose in a modified Krebs-Ringer buffer and during half-maximal stimulation of enzyme secretion with 100 pmol/ml cholecystokinin octapeptide (CCK-8), a dose-response study of 0.001-100 pmol/ml porcine galanin was performed. At concentrations of 0.001 and 0.01 pmol/ml, porcine galanin significantly stimulated insulin release (p < 0.05 and < 0.01, respectively) and also significantly enhanced CCK-8-stimulated amylase secretion (p < 0.05). Doses of 0.1 and 1 pmol/ml galanin resulted in a nonsignificant inhibition of insulin release, while 10 and 100 pmol/ml strongly inhibited the endocrine response (p < 0.001). However, concentration levels of 1-100 pmol/ml galanin did not affect CCK-8-stimulated amylase secretion. Rat galanin, tested at 0.01 and 10 pmol/ml, showed no significant difference from the effects of porcine galanin at the equipotent concentrations. It is concluded that the effect of galanin on exocrine pancreas, like the effect on endocrine functions, tends to be a direct one and that it could exert a modulatory influence on the level of neuronal transmission.

Identification of Somatostatin-14 and -28 in rat pancreatic juice by a new HPLC method

Recently we could demonstrate that in rats with pancreatic hypertrophy, somatostatin is secreted in higher concentrations into the pancreatic juice than into the portal vein blood. For measurement of juice somatostatin and to characterize the molecular forms, we established a new reverse-phase HPLC method, which we describe herein. This HPLC method, using a linear gradient system consisting of 0.2% heptafluorbutyric acid in 10 mM sodium acetate and acetonitrile, showed a stable recovery rate of about 85%. Applying the pure juice to this gradient system, we detect somatostatin-14 to be the major form of immunoreactive somatostatin (IRSS) in the pancreatic juice of the rat (5% of total IRSS). The remaining 35% were found to be somatostatin-28. The role of somatostatin in pancreatic juice is not known. It raises the hypothesis that it possibly interacts with the influences intraluminal intestinal growth factors. This study supports the assumption for the existence of an insuloacinar portal system to regulate exocrine pancreatic functions by islet hormones.

Glucose-dependent effects of pancreastatin on insulin and glucagon release

Pancreastatin (PST), a peptide isolated from porcine pancreas in 1986, has been reported to inhibit insulin and to stimulate glucagon secretion. Since both of these effects have been questioned, we investigated the effect of PST (20, 200, or 2000 pM) on hormone release in the isolated perfused rat pancreas at different glucose levels (1.7, 5.5, 11.1, and 16.7 mM). At 1.7 mM glucose, 20 pM PST had no significant effect on glucagon secretion, whereas 200 pM and 2 nM PST significantly inhibited glucagon release. At a concentration of 5.5 mM glucose, insulin output was not affected by PST in any of the concentrations tested. At 11.1 mM glucose, however, 200 pM and 2 nM PST significantly inhibited insulin output. At 16.7 mM glucose, insulin secretion was significantly reduced by all concentrations of PST tested. Unstimulated exocrine pancreatic secretion was not affected by PST in any of the experimental settings. We conclude that PST inhibits glucagon and insulin secretion dose-dependently, and these effects apparently are glucose-dependent. PST does not influence basal exocrine pancreatic secretion in vitro.

[Effect of pancreastatin on insulin secretion and the exocrine pancreas in rats]

Pancreastatin, a 49-amino-acid C-terminal amidated peptide, was isolated from porcine pancreas in 1986. It has been reported to inhibit insulin release and exocrine pancreatic secretion, but both these effects have been disputed. In the isolated perfused rat pancreas we therefore studied the effect of pancreastatin on insulin and exocrine pancreatic secretion. Neither basal exocrine pancreatic secretion, nor exocrine secretion stimulated by CCK-8, bombesin or secretin were affected by pancreastatin. 20 or 200 pM pancreastatin, however, significantly inhibited stimulated insulin release. We conclude that pancreastatin seems to be yet another inhibitory peptide, which--for unknown reasons--inhibits insulin release both in vivo and in vitro, but exocrine pancreatic secretion only in vivo.

Independence of GIP-induced insulin secretion from sympathetic and parasympathetic innervation in the isolated perfused rat pancreas

The incretin candidate GIP (gastric inhibitory polypeptide) is released from the gut by nutrients and can stimulate insulin secretion. Metabolic and hormonal factors have been shown to modulate insulin response to GIP. It is unknown, however, whether the autonomic nervous system, which itself controls insulin secretion, can modulate the insulinotropic effect of GIP. In the isolated perfused rat pancreas, we therefore investigated the influence of sympathetic and parasympathetic agonists and antagonists on the insulin response to GIP. As compared to control (6990 +/- 890 microU/10 min), the effect of either acetylcholine (29030 +/- 4600 microU/10 min), atropine (5880 +/- 1740 microU/10 min), norepinephrine (2520 +/- 750 microU/10 min), phentolamine (11380 +/- 1910 microU/10 min), isoproterenol (12740 +/- 2090 microU/10 min), propranolol (5600 +/- 880 microU/10 min), or GIP (29660 +/- 4490 microU/10 min) on insulin secretion was consistent with previous reports. The effects of the combined administration of GIP and either acetylcholine (48140 +/- 7540 microU/10 min), phentolamine (43930 +/- 4490 microU/10 min), norepinephrine (9000 +/- 1740 microU/10 min), or isoproterenol (36280 +/- 5210 microU/10 min) on insulin release were additive. Insulin response to GIP was resistant to atropine (24210 +/- 9470 microU/10 min) and propranolol (26450 +/- 4930 mu/10 min). We conclude that both GIP and the autonomic nervous system influence insulin secretion, but that they do so independently from each other.

Cytoprotective and dose-dependent inhibitory effects of prostaglandin E1 on rat pancreas treated with ciclosporin A

The prostaglandin E1 analogue rioprostil protects the pancreas from the noxious effect of ciclosporin A (CsA). To determine whether this cytoprotective action of rioprostil is dependent on or independent of inhibitory effects on pancreatic exocrine and endocrine secretion we studied the effect of different doses of rioprostil on pancreatic exocrine and endocrine secretions in the presence or absence of CsA. Rats received either CsA at a dose of 10 mg/kg body weight by tube feeding once in the morning, rioprostil at linearly increasing doses from 1.8 to 120 micrograms/kg body weight subcutaneously twice daily, a combination of both substances or NaCl. After 8 treatment days, the animals were operated on, and the pancreas isolated and arterially perfused. Insulin secretion was determined after stimulation with glucose, and amylase secretion after stimulation with CCK-8. Insulin and amylase secretion were significantly impaired by CsA. Rioprostil at doses of 1.8, 3.6 and 7.5 micrograms/kg body weight had no significant effect on insulin secretion in the absence of CsA but significantly improved insulin secretion in the presence of CsA. Higher doses of rioprostil significantly inhibited insulin secretion both in the presence or absence of CsA. Amylase secretion was not influenced by rioprostil at doses up to 15 micrograms/kg body weight but improved significantly amylase secretion in the presence of CsA. CsA blood and pancreatic tissue levels were not influenced by rioprostil at doses up to 120 micrograms/kb body weight. We conclude that the cytoprotective effect of the prostaglandin E1 analogue rioprostil against the noxious effect of CsA is dose dependent and is not related to its inhibitory action on endocrine and exocrine pancreatic secretion.