Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants.

Acute pancreatitis (AP) has been recognized as a presentation of patients with pancreatic carcinoma (PC). However, the natural history of patients with PC who present with AP as the first manifestation is largely unknown. The aim of this study was to determine the time between the presentation of AP and diagnosis of PC and what factors should alert the clinician to suspect underlying PC in patients with AP. Nineteen physicians completed the survey forms that encompassed 45 patients with a diagnosis of AP preceding a diagnosis of PC. Information included the patient's age, gender, race, conditions that could account for the AP, criteria for diagnosis of AP, severity of AP, criteria for diagnosis of PC, time between the diagnosis of AP and PC, pathology of the carcinoma, extension of the disease, treatment of PC, and survival after the diagnosis of PC. The study population consisted of 45 patients, 27 (60%) men and 18 (40%) women whose average age was 58 years (range, 32-89). Thirty-eight patients were Caucasian, five were black, one was Japanese, and one Arabian. The number of AP episodes before PC diagnosis ranged between one and 15 (mean + 2 SD). AP was mild in 40 (89%) and severe in five (11%). The time between the onset of AP and the diagnosis of PC averaged 34 weeks (range, 1-52). Symptoms on presentation of AP included abdominal pain 45 (100%), weight loss 15 (33%), and jaundice 3 (7%). CA 19-9 was available in 13 patients, eight of whom had levels >100 at the time AP was diagnosed. Abnormal imaging suggestive of PC was detected by ultrasonography in 17 patients, by computed tomography in 30, endoscopic retrograde cholangiopancreatography in 20, and endoscopic ultrasonography in three. Tissue diagnosis was obtained in 43 of 45 (96%) patients; by surgery in 25 patients, needle aspiration in 14, laparoscopy in one, autopsy in two, and lymph node in one. Pathology revealed adenocarcinoma in 37 patients, squamous cell carcinoma in two, undifferentiated carcinoma in two, islet cell in one, and cystadenocarcinoma in one. Surgical findings in 26 patients included 19 with a nonresectable lesion or metastasis and seven patients with resectable lesion for cure. Thirteen patients (28%) were alive 1 year after the diagnosis of PC. The patients had a mean of two (range, one to 15) episodes of AP before the diagnosis of PC, and this was associated with a delay of 34 weeks from AP to diagnosis of PC. Patients with PC who presented with AP were generally older than 50 years of age and the severity of the pancreatitis was mild. The survival rate of patients with PC who presented initially with AP was >25% at 1 year compared with 20% 1 year overall survival of patients with PC. AP seems to be an early presentation of PC and should be sought in patients with idiopathic pancreatitis.

When it's hard to swallow. What to look for in patients with dysphagia.

Swallowing disorders can be divided into oropharyngeal dysphagia and esophageal dysphagia. The most common cause of oropharyngeal dysphagia is cerebrovascular accidents; other causes may include oropharyngeal structural lesions, systematic and local muscular diseases, and diverse neurologic disorders. Esophageal dysphagia may result from neuromuscular disorders, mortality abnormalities, and intrinsic or extrinsic obstructive lesions. Through clinical history taking helps define the tpe of dysphagia and can guide diagnostic testing. Important questions to ask patients with the disorder include specific features of the dysphagia, its onset and progression, accompanying problems, and eating habits adopted to relieve symptoms. Videofluoroscopy should be the initial test in evaluating oropharyngeal dysphagia. Barium-contrast esophagography identifies most anatomic causes of dysphagia and some motor disorders and is better tha endoscopy at identifying extrinsic esophageal compression and intramural lesions not involving the esophageal mucosa. Cine-esophagography may provide clues to a possible esophageal motor disorder causing dysphagia. Endoscopy is the test of choice if obstruction or gastroesophageal reflux disease is suspected, because biopsies can confirm the presence of esophagitis and provide specific pathologic identification of the obstructive lesion. In addition, therapeutic dilatation of a stricture and removal of foreign bodies can be accomplished as part of the evaluation procedure. When no obvious source of dysphagia is apparent after radiologic and endoscopic assessment, manometry for possible motility disorder should be considered.

[Asymptomatic Addison disease: cause of striking reduction of insulin requirements in a patient with diabetes, Hashimoto thyroiditis and Basedow disease]. / Addison inaparente: causa de drástica reducción del requerimiento de insulina en una paciente con diabetes, tiroiditis de Hashimoto y enfermedad de Basedow.

We report a 30 years old woman with sporadic poliglandular autoimmune syndrome type II, first seen with an insulin-dependent diabetes mellitus and a Graves-Basedow disease that became spontaneously hypothyroid with positive antimicrosomal antibodies. Six years later she presented with persistent vomiting and a remarkable reduction in insulin requirements. She had low basal and stimulated-cortisol levels and the diagnosis of severe adrenal failure was reached. A CT scan showed normal adrenal glands, she did not have cutaneous hyperpigmentation nor evidences of mineralocorticoid deficit. A selective autoimmune damage of the fascicular zone was assumed but a selective damage of ACTH producing pituitary cells cannot be discarded. The importance of investigating adrenal function in cases of unexplained reduction of insulin requirements is emphasized.

Occult gastrointestinal bleeding. General overview and approach.

Occult gastrointestinal bleeding is most commonly defined as an acute or chronic loss of blood, the source of which has not been identified after gastroscopy, colonoscopy, and upper gastrointestinal series have been performed. As the title suggests, this article provides a general overview of this disorder. Specific topics discussed include etiology, diagnostic procedures, laboratory studies, radiologic procedures, radionuclide studies, angiography, and endoscopy.

The effect of vasoactive intestinal polypeptide on the lower esophageal sphincter in achalasia.

Vasoactive intestinal polypeptide (VIP) is one of the main neurotransmitters implicated in the relaxation of the lower esophageal sphincter (LES). The effect of exogenous VIP on LES motor activity was determined by esophageal manometry. LES pressure (LESP) and LES relaxation were compared in four healthy volunteers and in six patients with achalasia. The effects of intravenous doses of 1.5, 3, and 5 pmol.kg-1.min-1 of VIP were compared with placebo. Neither placebo nor 3 and 5 pmol.kg-1.min-1 of VIP produced any effect on esophageal motility in healthy volunteers. In achalasia the three doses of VIP caused a dose-dependent decrease in LESP with a significant improvement in LES relaxation. A dose of 5 pmol.kg-1.min-1 produced a maximal decrease of 51% in LESP. A beta-adrenergic agonist, isoproterenol, caused a decrease in LESP both in healthy volunteers and in patients with achalasia without improving LES relaxation. In summary, intravenous VIP improved LES relaxation and caused a decrease in LESP in patients with achalasia without affecting LESP in healthy volunteers, indicating that the LES muscle in achalasia is supersensitive to VIP. The current study suggests that a selective damage in the noncholinergic nonadrenergic innervation of the esophagus is in part responsible for the motor alteration seen in these patients. The findings and the inability of isoproterenol to improve LES relaxation despite decreasing LESP support a role in VIP as a indicator of LES relaxation.

The effect of transcutaneous nerve stimulation on sphincter of Oddi pressure in patients with biliary dyskinesia.

Vasoactive intestinal polypeptide (VIP) has been postulated as a neuropeptide with inhibitory neurotransmitter activity in nonadrenergic noncholinergic pathways. Transcutaneous electric nerve stimulation (TENS) relaxes the lower esophageal sphincter in patients with achalasia. Such response is accompanied by a 30% increase in VIP concentrations in the systemic circulation. Since the sphincter of Oddi (SO) receives a very dense VIP nerve supply, we evaluate the effect of TENS on SO motor activity and on VIP plasma concentrations in patients with biliary dyskinesia and in healthy volunteers. TENS was performed with a pocket stimulator for 45 min. SO pressure and VIP levels were obtained before and after 45 min of TENS. In patients with SO dyskinesia, TENS produced a significant decrease in SO pressure from 80.1 +/- 11.9 mm Hg to 58.3 +/- 9.7 mm Hg p less than 0.01); this was accompanied by a significant increase in VIP plasma levels from 21.1 +/- 0.5 pg/ml to 32.6 +/- 1.5 pg/ml (p less than 0.01). In healthy volunteers, TENS did not produce significant changes in SO pressure. However, a significant increase in VIP plasma values was observed (p less than 0.01). No significant changes in amplitude, duration and frequency of SO phasic contractions were observed in either of the two groups evaluated. We conclude that, in patients with SO dyskinesia, TENS decreases SO basal pressure, possibly by a direct action of the released VIP in the systemic circulation. In healthy volunteers, TENS increases VIP plasma values without significant effect on SO basal pressure. These findings suggest that the response to TENS may be mediated by VIP. It is also possible that the alterations seen in patients with biliary dyskinesia may be due to impairment of the VIP nerve supply at the level of the SO.

[Double sphincterostomy of pancreatic and choledochal sphincters in the treatment of chronic recurrent pancreatitis]. / La esfinterotomía doble del esfínter pancreático y coledociano en el tratamiento de la pancreatitis crónica recidivante.

The treatment of recurrent chronic pancreatitis is controversial. Some patients may have sphincter of Oddi motor abnormalities. Although widely used in the biliary tree, little data is available on endoscopic sphincterotomy of the pancreatic sphincter. This report describes 5 patients with recurrent chronic pancreatitis, who had pancreatic sphincterotomy for hypertensive sphincter of Oddi. Four patients continue long-term follow-up with marked reduction of chronic pain of attacks of recurrent pancreatitis. It is concluded that endoscopic sphincterotomy of the pancreatic sphincter may improve pain in chronic pancreatitis and may obviate the need for surgery.