Barriers to the use of tests for early detection of colorectal cancer in Chile

This study aimed to assess the use of colorectal cancer (CRC) tests for prevention and early detection, alongside exploring the associated barriers to these tests. A stratified national survey was conducted in Chile, involving 1893 respondents (with a 2.3% error margin and 95% confidence interval). Logistic and multinomial regression analyses were employed to examine variations in test utilization likelihood and barrier. We found that the key determinants for undergoing CRC tests included age, health status, possession of private health insurance, and attainment of postgraduate education. Notably, 18% and 29% of respondents covered by public and private insurance, respectively, cited personal prevention as the primary motivation for test uptake. The principal obstacle identified was lack of knowledge, mentioned by 65% of respondents, while 29% and 19% of the publicly and privately insured respectively highlighted lack of access as a barrier. The results of this study provide valuable insights into factors influencing CRC screening, aiming to inform public health policies for expanding national coverage beyond diagnosis and treatment to encompass preventive measures.

Pancreatic steatosis: A frequent finding in a Chilean population

INTRODUCTION AND AIMS

Pancreatic steatosis is an incidental radiologic finding in asymptomatic patients, and its clinical importance is unclear. Primary aim: to study the prevalence of pancreatic steatosis (PS) in consecutive patients registered at our hospital, that underwent computed axial tomography (CAT) scanning of the abdomen and pelvis, excluding known pancreatic diseases. Secondary aim: to review the association of PS with the demographic and clinical data of the patients, as well as with hepatic steatosis (HS).

MATERIALS AND METHODS

An observational study was conducted on adult patients that had CAT scans of the abdomen and pelvis.

DEFINITIONS

a) tissue density was measured in Hounsfield units (HU) in five 1 cm² areas of the pancreas, three areas of the spleen, and in segments VI and VII of the liver; b) fatty pancreas: a difference < -10 HU between the mean pancreas and mean spleen densities; and c) fatty liver: density < 40 HU. We registered the epidemiologic and laboratory data of the patients. The association of those factors with the presence of PS was analyzed using SPSS version 24.0 software, and statistical significance was set at a p < 0.05.

RESULTS

Of the 203 patients, PS was found in 61 (30%). The patients with PS were significantly older and had a higher body mass index. We found no significant association with the rest of the parameters studied, nor with HS (55 patients). None of the patients had symptoms attributable to a disease of the exocrine pancreas.

CONCLUSIONS

Fatty infiltration of the pancreas is a frequent finding in CAT scans, and its clinical importance is unclear. Aging of the population and the increase in obesity underline the need for future studies on PS.

Sarcomatoid carcinoma of the pancreas — a rare tumor with an uncommon presentation and course: A case report and review of literature

BACKGROUND

Sarcomatoid carcinoma of the pancreas (SCP) is a rare type of pancreatic neoplasm, and only a few cases have been described in the literature. Histologically, it is composed mostly of atypical spindle cells with apparent sarcomatous features.

CASE SUMMARY

This is a report of a 61-year-old Chilean woman who underwent medical investigation for acute abdominal pain. Computed tomography identified a solid tumor in the tail of the pancreas with features suspicious of malignancy. En-bloc distal pancreatectomy and splenectomy were performed to excise the tumor. Histopathology and immunohistochemistry were confirmatory of sarcomatoid carcinoma with lymphovascular invasion. After surgery, the patient did not receive chemotherapy. Previous studies indicate a poor prognosis for this type of malignancy. However, our patient has survived for 35 mo with no recurrence to date.

CONCLUSION

The case presented herein is a patient with an SCP with a rare presentation and long-term survival after surgery despite not receiving adjuvant chemotherapy.

NOD1 rs2075820 (p.E266K) polymorphism is associated with gastric cancer among individuals infected with cagPAI-positive H. pylori

Background

Helicobacter pylori is detected by pathogen recognition receptors including toll-like receptors (TLR) and nucleotide-binding oligomerization domain (NOD)-like receptors, eliciting an innate immune response against this bacteria. The aim of this study was to assess if polymorphisms of TLR2, TLR4, TLR5, NOD1 and NOD2 genes are associated with gastric cancer, in particular in individuals infected with H. pylori.

Results

A case-control study of 297 gastric cancer patients and 300 controls was performed to assess the association of 17 polymorphisms. Analyses performed under the allele model did not find association with gastric cancer. However, NOD1 rs2075820 (p.E266K) showed association with intestinal-type gastric cancer among H. pylori infected subjects (OR = 2.69, 95% CI 1.41–5.13, p = 0.0026). The association was not statistically significant in diffuse-type gastric cancer cases (OR = 1.26, 95% CI 0.63–2.52, p = 0.51). When the analyses were performed in patients carrying H. pylori strains harboring the cag pathogenicity island (cagPAI), we noticed significant association with NOD1 rs2075820 (OR = 4.90, 95% CI 1.80–3.36, p = 0.0019), in particular for intestinal-type gastric cancer cases (OR = 7.16, 95% CI 2.40–21.33, p = 4.1 × 10^− 4) but not among diffuse-type gastric cancer cases (OR = 3.39, 95% CI 1.13–0.10, p = 0.03).

Conclusions

NOD1 rs2075820 increases the risk of intestinal-type gastric cancer among individuals infected with H. pylori, particularly in those harboring the cagPAI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40659-021-00336-4.

A phase I, randomized, double-blind study to assess the safety, tolerability and efficacy of the topical RORC2 inverse agonist PF-06763809 in participants with mild-to-moderate plaque psoriasis

BACKGROUND

Transcription factor retinoic acid-related orphan receptor 2 (RORC2/RORγT) mediates interleukin (IL)-17A and IL-17F expression. IL-17A plays a central role in the pathogenesis of several inflammatory disorders, including psoriasis. The RORC2 inhibitor PF-06763809 has been hypothesized to inhibit IL-17A production in T-helper 17 (Th17) cells, thereby reducing psoriasis symptoms.

AIM

To assess the safety, tolerability and effect on skin infiltrate thickness of PF-06763809 in participants with mild/moderate chronic plaque psoriasis.

METHODS

This was a randomized, double-blind, first-in-human study (trial registration: ClinicalTrials.gov NCT03469336). Participants received each of the following six treatments once daily for 18 days: three topical doses (2.3%, 0.8%, 0.23%) of PF-06763809, a vehicle and two active comparators (betamethasone and calcipotriol). Primary endpoints included change from baseline in psoriatic skin infiltrate thickness [echo-poor band (EPB) on ultrasonography] at Day 19, and safety. Change in psoriasis-associated gene expression (Day 19), evaluated by real-time reverse transcription PCR of skin biopsies, was an exploratory endpoint.

RESULTS

In total, 17 participants completed the study. Change from baseline in the EPB on Day 19 for all three doses of PF-06763809 was not significantly different from that of vehicle (P > 0.05). A significant reduction in EPB from baseline was observed with betamethasone on Day 19 relative to all other treatments (P < 0.0001). Treatment-related adverse events were mild/moderate. There were no significant differences in gene expression on Day 19 between vehicle and PF-06763809-treated skin lesions.

CONCLUSION

Using a psoriasis plaque test design, PF-06763809 was found to be well tolerated with an acceptable safety profile in participants with psoriasis, but without reduction in skin infiltrate thickness or disease biomarkers.

[Variceal and non-variceal upper gastrointestinal bleeding. Analysis of 249 hospitalized patients]

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is one of the main reasons of hospitalization due to gastrointestinal causes. Reported mortality rates range from 5 to 12%.

AIM

To determine hospital mortality and associated risk factors in hospitalized patients with UGIB. To compare the clinical characteristics and outcomes of patients with variceal versus non-variceal UGIB.

MATERIAL AND METHODS

Review of medical records of 249 patients (62% males) discharged with the diagnosis of UGIB at a clinical hospital between 2015 to 2017. Demographic and clinical characteristics and adverse clinical outcomes (surgery, length of hospital stay and in-hospital mortality) were recorded. A comparative analysis between patients with Variceal and Non-variceal UGIB was carried out.

RESULTS

Seventy two percent of UGIB were non-variceal (peptic ulcer in 44%). Two patients required surgery (both died). Median of length of hospital stay was seven days (interquartile range (IQR) 4-13). Overall hospital mortality was 13 and 4% in variceal and non-variceal UGIB, respectively (p = 0.024). The variables associated with mortality were: red blood cell transfusion (odds ratio (OR): 18.7, p < 0.01), elevated creatinine on admission (OR: 3.30, p = 0.03) and variceal bleeding (OR: 3.23, p = 0.02).

CONCLUSIONS

Hospital mortality of UGIB remains high, especially in variceal UGIB. Elevated creatinine levels on admission, the need of transfusion of red blood cells and variceal etiology are risk factors for mortality.

Prevalence of clarithromycin resistance in Helicobacter pylori in Santiago, Chile, estimated by real-time PCR directly from gastric mucosa

BACKGROUND

Current available treatments for Helicobacter pylori eradication are chosen according to local clarithromycin and metronidazole resistance prevalence. The aim of this study was to estimate, by means of molecular methods, both clarithromycin and metronidazole resistance in gastric mucosa from patients infected with H.pylori.

METHODS

A total of 191 DNA samples were analyzed. DNA was purified from gastric mucosa obtained from patients who underwent an upper gastrointestinal endoscopy at an university hospital from Santiago, Chile, between 2011 and 2014. H.pylori was detected by real-time PCR. A 5'exonuclease assay was developed to detect A2142G and A2143G mutations among H.pylori-positive samples. rdxA gene was sequenced in samples harboring A2142G and A2143G mutations in order to detect mutations that potentially confer dual clarithromycin and metronidazole resistance.

RESULTS

Ninety-three (93) out of 191 DNA samples obtained from gastric mucosa were H.pylori-positive (48.7%). Clarithromycin-resistance was detected in 29 samples (31.2% [95%CI 22.0-41.6%]). The sequencing of rdxA gene revealed that two samples harbored truncating mutations in rdxA, one sample had an in-frame deletion, and 11 had amino acid changes that likely cause metronidazole resistance.

CONCLUSIONS

We estimated a prevalence of clarithomycin-resistance of 31.8% in Santiago, Chile. Three of them harbor inactivating mutations in rdxA and 11 had missense mutations likely conferring metronidazole resistance. Our results require further confirmation. Nevertheless, they are significant as an initial approximation in re-evaluating the guidelines for H.pylori eradication currently used in Chile.

Role of cytokine gene polymorphisms in gastric cancer risk in Chile

AIM

To assess the role of pro- and anti-inflammatory polymorphisms in gastric cancer susceptibility.

PATIENTS AND METHODS

We genotyped 12 polymorphisms in eight cytokine genes (Interleukin-1β -IL1B-, IL8, IL17A, IL17F, IL32, tumor necrosis factor-α -TNF-, IL1RN, IL10) in a case-control study of 147 patients with gastric cancer and 172 controls.

RESULTS

Single polymorphism analysis revealed an association between the IL10 -592C>A single nucleotide polymorphism and cases with moderately- or well-differentiated tumors [AA vs. GG, odds ratio (OR)=3.01; 95% confidence interval (CI)=1.08-8.50]. We further analyzed gene-gene interactions using a combined attribute network implemented in multifactor dimensionality reduction software. The analysis revealed an interaction between IL8 -251A>T and IL32 rs28372698 SNPs among cases with moderately- or well-differentiated tumors. Homozygosity for both IL8 -251T and IL32 T alleles increases the odds for developing gastric cancer up to 2.63-fold (OR=2.63; 95% CI=1.15-6.03). This association was higher compared to the homozygosity for the IL8-251 T allele alone (OR=1.11; 95% CI=0.51-2.43) or the IL32 T allele alone (OR=1.21; 95% CI=0.54-2.72).

CONCLUSION

These findings suggest that IL10 -592C>A increases the odds for developing gastric cancer. An interaction between IL8 -251A>T and IL32 rs28372698 SNPs is also proposed.

Making health care safer II: an updated critical analysis of the evidence for patient safety practices

OBJECTIVES

To review important patient safety practices for evidence of effectiveness, implementation, and adoption.

DATA SOURCES

Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders.

REVIEW METHODS

The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption.

RESULTS

From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption.

CONCLUSIONS

The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

Posttraumatic stress and co-morbidity following myocardial infarction among older patients: the role of coping

This study aimed to investigate co-morbidity and coping strategies among older patients who suffer from different levels of posttraumatic stress disorder (PTSD) following myocardial infarction. Ninety-six older myocardial infarction (MI) patients were recruited from two general practices and completed the Posttraumatic Stress Diagnostic Scale (PDS), the General Health Questionnaire-28 (GHQ-28) and the COPE Scale. Ninety-two older patients with no previous MI experience constituted the control. Using the PDS, 30, 42 and 28% had full, partial and no-PTSD respectively. There were significant differences between the patient groups and the control on all GHQ-28 sub-scales. Significant differences were also identified between the patient groups in the following coping strategies: seeking emotional social support, suppression of competing activities, restraint coping, focusing on and venting of emotion, mental and behavioural disengagement. Controlling for bypass surgery, previous mental health difficulties, angioplasty, heart failure and angina, MANCOVA results did not change the overall results of the GHQ-28 but changed the results of coping in that seeking emotional social support and behavioural disengagement stopped being significant. Coping was a partial mediator between different levels of post-MI PTSD and co-morbidity. Depending on the severity of PTSD symptoms, co-morbidity and coping strategies can vary among older patients. Older patients with full-PTSD tend to use both maladaptive coping strategies as well as problem-focused coping.

[heparin and insulin treatment of acute pancreatitis caused by hypertriglyceridemia. Experience of 5 cases]

BACKGROUND

Hypertriglyceridemia over 1,000 mg/dl can provoke acute pancreatitis and its persistence can worsen the clinical outcome. On the contrary, a rapid decrease in triglyceride level is beneficial. Plasmapheresis has been performed in some patients to remove chylomicrons from the circulation, while heparin and/or insulin have been administered in some other cases to rapidly reduce blood triglycerides. Heparin and insulin stimulate lipoprotein-lipase activity and accelerate chylomicron degradation.

AIM

To report five patients with acute pancreatitis treated with heparin and insulin.

PATIENTS AND METHODS

Five patients (4 females and 1 male) seen in the last two years, who suffered acute pancreatitis induced by hypertriglyceridemia are reported. Initial blood triglyceride levels were above 1,000 mg/dl (range 1,590-8,690 mg/dl). Besides the usual treatment of acute pancreatitis, heparin and/or insulin were administered intravenously in continuous infusion. Heparin dose was guided by usual parameters of blood coagulation, and insulin dose, by serial determinations of blood glucose. Pancreatic necrosis was demonstrated in 4 patients.

RESULTS

Serum triglyceride levels decreased to < 500 mg/dl within 3 days in all cases. No complication of treatment was observed and all patients survived. Early and late complications of pancreatitis occurred in one patient.

CONCLUSION

Administration of heparin and/or insulin is an efficient alternative to reduce triglyceride levels in patients with acute pancreatitis and hypertriglyceridemia.

[Digestive refeeding in acute pancreatitis. When and how?]

BACKGROUND

Digestive refeeding in acute pancreatitis represent a difficult issue. It requires the resolution of intestinal ileus and carries a risk of reactivation.

AIM

To evaluate criteria that may guide in early refeeding avoiding unnecessary prolonged fasting.

PATIENTS AND METHODS

Thirty patients with acute pancreatitis were evaluated in a prospective trial. The severity of the pancreatitis was evaluated according to APACHE II score and Balthazar CT scan alterations. The criteria proposed to start early refeeding were absence of nausea and vomiting, decreased abdominal pain, presence of bowel sounds and lowering of serum amylase levels. Balthazar CT scan classification, was used to decide between oral or enteral refeeding.

RESULTS

Eighty percent of patients had alterations in pancreatic density, necrosis or pancreatic or peripancreatic liquid collections in the CT scan (corresponding to Balthazar stages C, D, or E). Ten patients fullfilled the criteria for enteral refeeding at 8.1 +/- 3.5 days (range 3 to 15 days), and 21 patients fulfilled criteria fo enteral refeeding at 8.7 +/- 4.5 (range 4-19). No patient had a reactivation of his pancreatitis.

CONCLUSIONS

Digestive refeeding can be done safely by using the criteria proposed in this study. Pancreatic necrosis or peripancreatic fluid collections do not contraindicate refeeding. Oral feeding may be employed (as the first option) in selected patients, without increasing the risk of complication, regardless of CT scan alterations of the pancreas.

[Long nasojejunal feeding tube: endoscopic method for placing and its use for enteral nutrition in acute pancreatitis]

BACKGROUND

Enteral nutrition can be useful for the feeding of patients with acute pancreatitis, specially in the later phases of the disease.

AIM

To describe an endoscopic placement method for long nasojejunal tubes and assess its efficacy. To communicate a preliminary experience with enteral nutrition in patients with acute pancreatitis.

PATIENTS AND METHODS

An endoscopic placement method for nasojejunal tubes is described. In 24 patients with acute pancreatitis, 28 tubes were placed using this method, after the second week of evolution. In 15 patients with brain damage, traditional nasojejunal feeding tubes were placed without endoscopy. The position of both types of tubes was determined by fluoroscopy with the aid of contrast media.

RESULTS

The endoscopic placement method was simple and the tube was placed beyond the ligament of Treitz in all patients. No traditional tube was placed in the jejunum and contrast media filled the duodenum in all cases. In patients with acute pancreatitis, enteral nutrition was well tolerated, 5 patients had a higher stool frequency and one, had an asymptomatic increase in serum amilase levels.

CONCLUSIONS

Long nasojejunal tubes can be easily placed beyond the ligament of Treitz with endoscopic aid and can be used for enteral feeding in patients with acute pancreatitis.

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.

[Endoscopic manometry of Oddi's sphincter]

BACKGROUND

Endoscopic manometry is the gold standard for the diagnosis of sphincter of Oddi dysfunction.

AIM

To report the results of the first 30 endoscopic manometries of sphincter of Oddi performed in a Gastroenterology Service.

PATIENTS AND METHODS

Thirty manometries were performed in 28 patients aged 30 to 70 years old (14 females). The papilla was cannulated with a perfused catheter, measuring pressure with external transducers.

RESULTS

Deep cannulation of the papilla was achieved in 88%. Procedure-related complications were not observed in these cases. Normal values were registered in 11 cases with a basal sphincter pressure 15.6 +/- 10.7 mm Hg, contractions with an amplitude of 92.3 +/- 35.7 mm Hg and 6.0 +/- 2.4/min frequency. The clinical suspicion of hypertonic dyskinesis was confirmed in 5 cases with an elevated basal pressure of 43.69 +/- 13.3 mm Hg, an increased frequency of contractions ("tachyoddia") in one, and large spastic contractions of high pressure in other case. In 3 of 5 cases with common bile duct stones, a predominance of retrograde propagation of the contractions was observed with normal pressure. Variable manometric results were observed after endoscopic papillotomy observing a scale from the complete absence of motor activity to normal sphincter function.

CONCLUSIONS

Endoscopic manometry is a reasonably safe method, of great importance in the diagnosis of functional disorders of the sphincter of Oddi.

Degeneration of intrapancreatic nerve fibers after chronic alcohol administration in mice

CONCLUSION

These results provide morphological evidence for an alcohol-induced selective intrapancreatic nerve degeneration. This affected mainly the nerve fibers that are inhibitory of the exocrine pancreas, and might represent the morphological background of hypersecretory state of the pancreas in chronic alcoholism.

METHODS

Intrapancreatic intrinsic nerves were studied by immunohistochemistry and electron microscopy after 4 mo of alcohol consumption and compared with control mice.

RESULTS

A dense network of nerve fibers was observed in the normal mouse pancreas around the blood vessels and ending on the exocrine cells. The presence of VIP, NPY, PP, SP, and serotonin in these nerves was demonstrated by immunohistochemistry. Four months of alcohol consumption did not result in apparent morphological changes of the pancreas. However, the majority of periacinar nerve terminals showed degenerative changes. Synaptic vesicles were diminished in number in some other nerve processes, whereas the perivascular nerve fibers were relatively well preserved. A slight decrease was found in the intensity of VIP and SP immunoreactivity, and the PP fibers almost disappeared.

[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.

[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.

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.

Anion channels in a human pancreatic cancer cell line (Capan-1) of ductal origin

Transepithelial solute transport and bicarbonate secretion are major functions of pancreatic duct cells, and both functions are thought to involve the presence of chloride channels in the apical membrane of the cell. After being isolated from a human pancreatic adenocarcinoma, the Capan-1 cell line conserves most of the properties of ductal cells and thus constitutes a useful system for investigating the role of chloride channels. Using patch-clamp techniques, we identified three different chloride-selective channels in the apical membrane of confluent Capan-1 cells. Two were non-rectifying chloride channels with low (50 pS) and high (350 pS) unitary conductances. Both channels were active in cell-attached recordings, and they were consistently located together in the same patch. Maxi Cl- channels displayed multiple subconductance states, and were reversibly inactivated by either positive or negative voltage changes, which indicates that they were optimally opened at the cell resting potential. The third was an outwardly rectifying chloride channel with a unitary conductance of 38 pS and 70 pS at negative and positive potentials respectively. Rectifying Cl- channels were clustered in discrete loci. They were silent in situ, but became active after patch excision. In inside-out excised patches, the three channels displayed a high selectivity for Cl- over monovalent cations (Na+ and K+) and gluconate. They were blocked by 20-200 microM 4,4'-diisothiocyanatostilbene-2,2'-disulfonic acid (DIDS) and were insensitive to changes in the Ca2+ concentration. Our results show that the apical membrane of Capan-1 cells contains a high density of chloride channels; these channels may provide pathways for transepithelial solute transport as well as for bicarbonate secretion.

CCK and PYY do not participate in the delayed inhibition of pancreatic secretion, after stimulation by duodenal oleic acid infusion

The role played by CCK in the stimulation of pancreatic secretion by duodenal infusion of oleic acid in conscious rats was studied using a potent and specific CCK receptor antagonist. CR-1409 did not alter basal secretion, which does not require CCK. The three doses of CR-1409 that were used (2, 4 and 8 mg/kg/h) suppressed the protein response to duodenal infusion of oleic acid and significantly enhanced the delayed inhibition normally observed in control rats (-81%, -87% and -88% vs. -51% of basal in controls). CR-1409 dose-dependently reduced the volume of pancreatic secretion after duodenal infusion of oleic acid (0.40 +/- 0.02, 0.36 +/- 0.02, 0.34 +/- 0.03 vs. 0.48 +/- 0.04 ml/30 min for 2, 4, 8 mg/kg/h and controls, respectively) and revealed a delayed inhibition of volume and a slight reduction of bicarbonate secretion. CCK appears to be directly responsible for the protein and also water response to duodenal infusion of oleic acid, and to be indirectly involved in bicarbonate stimulation. PYY antiserum significantly augmented protein output after duodenal infusion of oleic acid (10.75 +/- 1.40, 14.10 +/- 1.60 vs. 8.60 +/- 1.20 mg/30 min, 1 microliter, 2 microliters and controls), but failed to modify the delayed inhibition: PYY modulates the response to duodenal infusion of oleic acid and is not involved in the delayed inhibition, which was shown to be also present for volume, but which is normally masked by the action of CCK.

Involvement of tubular complexes in pancreatic regeneration after acute necrohemorrhagic pancreatitis

Localized acute necrohemorrhagic pancreatitis was induced in rats by multiple trypsin injections. Morphological alterations were monitored by light and electron microscopy until complete recovery. In the acute phase, typical pictures of focal acute necrohemorrhagic pancreatitis were observed. In the postacute phase, fibrosis and tubular complexes are characteristic of damaged areas. Tubular complexes appear from the dedifferentiation of acinar cells. They are characterized by duct-like cells bordering wide, empty luminae. In the recovery phase, cellular proliferation was accompanied by differentiation, with progressive acquisition of the morphological characteristics of acinar cells at the periphery of the tubular complexes. In that instance, cellular proliferation was concomitant with the development of collagen septa in tubular complexes. In these structures both duct-like and acinar-like cells presented mitoses. Cell division persisted in the dedifferentiated cells until tubular complexes disappeared. A very similar process was observed in the embryonic pancreas, where organized parenchyma originated from proliferation and differentiation of protodifferentiated cells. We concluded that pancreatic repair following necrohemorrhagic pancreatitis involves proliferation of cells from intact acini and from tubular complexes, at variance with edematous pancreatitis, where regeneration is exclusively due to acinar cell proliferation.

Course and regression of acute interstitial pancreatitis induced in rats by repeated serial subcutaneous cholecystokinin-octapeptide injections

The aim of this study was to examine histologic and biochemical alterations in experimental acute interstitial pancreatitis (AIP) induced by serial repeated supramaximal cholecystokinin-octapeptide (CCK-OP) stimulation in rats. High doses of CCK-OP (60 micrograms/kg body wt) were administered subcutaneously (sc) six times at hourly intervals for 1 d (Group I) or for 3, 5, or 7 d (Group II). Rats were killed after 1, 3, 5, 7, and 10 d in both groups and also after 13, 20, and 27 d in Group II. During the course of the AIP, the morphological alterations were more pronounced in the repeatedly treated rats, but their appearance and disappearance essentially occurred in parallel in the two groups. Increased mitotic activity of the centroacinar and acinar cells were observed in d 5 and rose further even in Group II. The pancreatic weight and the protein and DNA contents reached a minimum on d 5 in both groups. The lowest enzyme activities did not occur in parallel. Thereafter, functional regeneration occurred despite continuing CCK-OP overstimulation in Group II. The toxicity of repeated CCK-OP hyperstimulation, thus, was limited: after its fifth administration, it failed to further aggravate the acute pancreatic damage or prevent the regeneration. This might be explained by a decreased CCK-OP sensitivity of the preexisting acinar cells, and/or increased CCK-OP tolerance of newly-formed ones.

Prostaglandin F2 alpha and prostacyclin tissue levels in early phases of trypsin-induced acute pancreatitis in rats

Local variations of prostaglandin (PG) I2 and F2 alpha were studied in the pancreatic tissue during the first hour of an acute experimental necrohemorrhagic pancreatitis. The local pancreatitis was induced by trypsin injection into the interstitium of the splenic part of rat pancreas, and a saline injection was given into the interstitium in the duodenal part of the same pancreas as control. PGF2 alpha level was measured by specific radioimmunoassay (RIA), and the stable degradation product of PGI2, the 6-keto-PGF1 alpha, was determined also by RIA as an index of PGI2 level. The results were compared between the two regions and with control intact pancreata. The PGI2 level transiently decreased, whereas the PGF2 alpha increased in the region of localized hemorrhagic pancreatitis when compared with the intact pancreata. By contrast, the quickly disappearing edematous reaction induced by saline injection was accompanied by opposite changes in the two PGs studied: PGI2 was transiently elevated and PGF2 alpha diminished. In consequence, the ratio of the two PGs was shifted in favor of PGI2 in a transient edematous reaction and in favor of PGF2 alpha in hemorrhagic pancreatitis. It was concluded that PGI2 plays some protective role while PGF2 alpha might be one of the aggressive mediators in the inflammatory process. Their biological importance must be limited since PGF2 alpha alone did not induce pancreatitis nor did PGI2 protect against the trypsin-induced local pancreatitis.

[Morphologic and biochemical changes in acute experimental interstitial pancreatitis]

Repeated subcutaneous injections of cholecystokinin-octapeptide has brought about an acute interstitial pancreatitis in rats. The aim of the experiment was the study of histological and biochemical alterations with special regard to regeneration phenomena. The treatment was carried out for 1 (group 1), 3,5 and 7 (group 2) days. Morphological alterations were more pronounced in group 2 than in group 1, but the pathological process was principally similar in both groups. Lowest values of pancreatic weight, protein and DNA content were attained in both groups at day 5. After this, protein and DNA started to increase. Hyperstimulation with CCK-OP on day 5 did not increase the degree of pancreas damage, nor did it prevent morphological and functional regeneration. The reason of this may be the decreased CCK-OP sensitivity of pancreatic acinar cells and/or the increased CCK-OP tolerance of newly formed acinar cells.

Bilateral renal malacoplakia in systemic lupus erythematosus and adrenogenital syndrome

We report a case of an 8-year-old girl with adrenogenital syndrome secondary to adrenocortical hyperplasia. Thirteen years later systemic lupus erythematosus developed with lupus nephritis. In spite of complex continuous immunosuppressive therapy, she died from terminal renal failure. At autopsy, extensive bilateral renal malacoplakia was discovered. The role of recurrent urinary tract infections and of immunological disturbances in the pathogenesis of malacoplakia is discussed.

Temporary pseudochronic lesions during the recovery of acute necrohemorrhagic pancreatitis in rabbits

Acute necrohemorrhagic pancreatitis was induced in rabbits by multiple interstitial trypsin injections in the body of the pancreas. The time course of regeneration was followed for 12 weeks. Chronic pancreatitis-like changes persisted for 4 weeks in all experimental animals, and the recovery was complete after 12 weeks. Reversible fibrosis and regressive acinar changes ("tubular complexes") were most severe in the region of the trypsin injections. Three-dimensional reconstruction of the pancreas showed an anastomosing tubular arrangement in the areas of "pseudochronic pancreatitis" but not in the normal pancreas.

Inactivation of cholecystokinin octapeptide by normal and cirrhotic liver in rats

In anesthetized rats, a marked decrease in CCK-OP activity and, to a far lesser extent, in the pancreatic secretory effect of CCK-33 were found after portal administration, compared to the femoral route. Changes in the biological activity of CCK-OP were further investigated after 30 min incubation with different subcellular liver fractions (1000 X g, 12,000 X g, microsomal fraction with or without NADPH). All the subcellular liver fractions caused an approximately 70% decrease in the CCK-effect, as calculated from dose-response relationships. The inactivation of CCK-OP after incubation with microsomal fractions of thioacetamide (TAA)-induced cirrhotic liver did not differ from that of control rats. The CCK-OP dose-response curves were similar in cirrhotic and control rats, but the pancreatic secretion was sustained to a greater extent and the inhibitory effect of supramaximal stimulation was delayed in cirrhotic rats. It was concluded that CCK-OP can be inactivated by liver proteins present in microsomal fractions, by a NADPH-independent mechanism. This inactivation did not diminish in liver cirrhosis. There were no changes in CCK-OP elimination in cirrhotic rats in vivo, thus pancreatic hypertrophy in experimental cirrhosis must be explained by other mechanisms.