Outcomes of patients with cystic fibrosis undergoing lung transplantation with and without cystic fibrosis-associated liver cirrhosis.

People with severe cystic fibrosis (CF) lung disease with co-existent CF-associated liver disease (CFLD) are often excluded from consideration of sole lung transplantation, largely because of the concerns that they will subsequently develop hepatic decompensation. This retrospective cohort study aimed at determining whether patients with severe cirrhosis caused by CFLD have any differences in perioperative and relevant post-transplant outcomes compared to CF patients without CFLD when undergoing sole lung transplantation. Six patients with CFLD were matched with 18 CF patients without CFLD undergoing sole lung transplant at the same institution. There were no differences in total operative time or intra-operative requirements for cardiopulmonary bypass or blood products. Over a period of five yr post-transplant, no differences were observed between the two groups in body mass index, six-min walk, lung function, and survival. None of the CFLD subjects developed variceal bleeding; however, one developed hepatocellular and renal failure at four yr post-transplant and is being assessed for liver-kidney transplant. One additional patient with CFLD required repeat lung transplantation for bronchiolitis obliterans syndrome. This study provides evidence that CF patients with liver cirrhosis caused by CFLD can safely be considered for sole lung transplantation provided there is no evidence of significant hepatocellular dysfunction with decompensated cirrhosis or hepatic synthetic failure.

Cystic fibrosis modifier genes related to Pseudomonas aeruginosa infection.

Cystic fibrosis (CF) is one of the most common life-shortening genetic disorders, and the CF transmembrane conductance regulator (CFTR) is the major causal gene. However, a substantial clinical variability among patients with identical CFTR genotypes suggests the presence of modifier genes. We tested the effect of four genes involved in Pseudomonas aeruginosa infection. Analysis of a primary cohort detected eight candidate polymorphisms that were genotyped in the secondary cohort of 1579 patients; lung function and age at first infection with P. aeruginosa were considered as the phenotypes. Both additive and codominant models were considered, adjusting for confounding variables but not for multiple comparisons. In the secondary cohort, heme oxygenase-1 (HMOX1) rs2071749 had the most significant effect on lung function in the pediatric group (P=0.01; P(corrected)=0.03), and complement factor 3 (C3) rs11569393 and HMOX1 rs2071746 in the adult groups (P=0.03 for both variants; P(corrected)=0.16, 0.09). No polymorphism of complement factor B (CFB) or toll-like receptor 4 (TLR4) had a significant modifying effect on lung function in either group. We have identified two genes that showed nominal association with disease severity among CF patients. However, because of the multiple comparisons made, further studies are required to confirm the interaction between these modifying genes and CFTR.

Colipase and maximally activated pancreatic lipase in normal subjects and patients with steatorrhea.

Human pancreatic lipase in duodenal secretions was studied under conditions of maximal activation by porcine colipase and maximal inhibition by sodium taurodeoxycholate. In almost all samples, total lipase activity in 4 mM sodium taurodeoxycholate was activated by the addition of porcine colipase. Activation was linear until saturation by cofactor was reached, and maximum activity was greater than that obtained in the absence of bile salts. At pH 8.0 in 4 mM sodium taurodeoxycholate, lipase activity was due to pancreatic lipase in samples from normal and steatorrheic individuals and was proportional to the concentration of endogenous colipase in samples that could be activated by exogenous colipase. In these samples, therefore, colipase activity could be conveniently assayed as the lipase activity at pH 0.8 in 4 mM sodium taurodeoxycholate. Colipase to total pancreatic lipase ratios varied widely from individual to individual and on average were significantly lower in steatorrheic patients. In individual samples, colipase secretion was stimulated by pancreozymin and secretin roughly in parallel with total pancreatic lipase, but some variation in the ratio of the two was often seen in successive collection periods. Because pancreatic lipase is usually unsaturated with respect to cofactor, lipolytic activity in duodenal secretions may be finely controlled by modulation of colipase secretion.

Radiologic manifestations of malabsorption: a nonspecific finding.

Children demonstrating a radiologic malabsorption pattern on small bowel follow-through study performed for other reasons are frequently subjected to intensive gastrointestinal investigations, even in the absence of clinical manifestations of malabsorption. To determine the usefulness of this radiologic finding, the clinical findings of all patients with the typical malabsorption pattern on small bowel follow-through examination were reviewed retrospectively. The presence of a malabsorption pattern was based on three radiologic criteria: flocculation and segmentation of barium, thickening of mucosal folds, and dilation of intestinal loops. Thirteen patients fulfilled the criteria for radiologic malabsorption pattern, but six (46%) had no clinical evidence of malabsorption, according to 3- to 5-day fecal fat analysis. In addition, five of these patients had normal mucosal histologic findings on duodenal biopsy. It was concluded that radiologic malabsorption pattern is a nonspecific finding, and in the absence of other clinical features suggestive of malabsorption or growth failure further investigations may not be justified.

Lavage treatment of distal intestinal obstruction syndrome in children with cystic fibrosis.

The efficacy, adverse reactions, and long-term effects of intestinal lavage treatment with a balanced electrolyte solution (Golytely) was evaluated in patients with cystic fibrosis and distal intestinal obstruction syndrome. Twenty-two patients with cystic fibrosis (mean age 21.8 years, range 14 to 34 years, 15 boys or men) who sought medical attention because of abdominal pain and a mass in the right iliac fossa received Golytely, 5.6 +/- 1.9 L (mean +/- 1 SD), either orally (n = 14) or via nasogastric tube (n = 8) during 5.6 +/- 2.4 hours. No serious side effects occurred. Serum electrolyte values remained within normal limits. Body weight did not change significantly. Minor adverse reactions included bloating (n = 12), nausea (n = 8), vomiting (n = 1), and chills (n = 3). All but one patient reported impressive relief of symptoms and remained pain free for an average of 3 months (range 1 to 19 months). Symptoms of abdominal pain and radiologic signs of fecal impaction assessed before and after lavage both decreased significantly (P less than .0001). During follow-up (mean 15.2 months, range 4 to 26 months), 11 patients required a total of 38 (range one to nine) additional doses of Golytely. Seven patients drank the solution at home (21 treatments); only two patients chose a nasogastric tube. In ten patients with symptoms of recurrent distal intestinal obstruction syndrome prior to institution of therapy, duration of hospitalization was significantly reduced by this treatment (5.1 +/- 7.6 v 2.3 +/- 6.3 hospital days per annum, P less than .02).(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment failure in celiac disease due to coexistent exocrine pancreatic insufficiency.

A 17-year-old white adolescent had a history of chronic diarrhea, delayed puberty, and growth failure. Investigations excluded cystic fibrosis, Shwachman syndrome, and endocrine causes of growth failure. Severe steatorrhea was diagnosed from fecal fat studies, and a jejunal suction biopsy showed total villus atrophy, consistent with a diagnosis of celiac disease. Following introduction of a gluten-free diet, his appetite and growth improved, but he continued to have abdominal discomfort and loose offensive bowel motions. One year later, severe steatorrhea was present. A repeat jejunal biopsy showed partial recovery of villus architecture. Serum immuno-reactive trypsinogen level was low, which was highly suggestive of exocrine pancreatic failure. Results of quantitative pancreatic stimulation test confirmed the presence of primary pancreatic insufficiency. After introduction of oral pancreatic enzyme supplements with meals, his gastrointestinal symptoms resolved and growth velocity accelerated. Previously, primary pancreatic insufficiency has only been described in elderly patients with long-standing untreated celiac disease. This case, however, emphasizes that pancreatic failure can occur with celiac disease at any age. Determination of a serum immunoreactive trypsinogen level should be considered a useful screening tool for pancreatic insufficiency in patients with celiac disease who have not responded to a gluten-free diet.

Peptic ulcer disease in children: etiology, clinical findings, and clinical course.

The records of all children with peptic ulcer disease at the Hospital for Sick Children were retrospectively evaluated, excluding neonates, throughout a 5-year period. Only cases with a definite ulcer crater identified either at endoscopy or at surgery were included. There were 36 patients, 20 boys and 16 girls. Duodenal ulcers were more common than gastric ulcers (2.8:1). Ages ranged from 3 months to 17 years, with a mean age of 10 years. Patients were reviewed with respect to etiology of peptic ulcer disease, age when first examined, initial symptoms, and clinical course. Patients were divided into two groups, those with primary (n = 19) and those with secondary (n = 17) peptic ulcer disease. All peptic ulcers in patients younger than 10 years of age were secondary in nature. Secondary ulcers occurred generally in association with a severe underlying illness (11/17), and many ulcers necessitated emergency surgery because of perforation and/or severe hemorrhage (8/17). None of these patients had chronic or recurrent symptoms. In contrast, in children with primary peptic ulcer disease, initial symptoms were more benign. Most patients had abdominal pain and only one required emergency surgery. Children with primary duodenal ulcer disease had a high incidence of recurrent symptoms (67%), however, with surgery for intractable disease necessitated in 40%. Single-contrast barium meals were found to be unreliable in establishing a diagnosis of peptic ulcer disease, particularly cases of gastric ulcer disease.

Exclusion of linkage of Shwachman-Diamond syndrome to chromosome regions 6q and 12q implicated by a de novo translocation.

Shwachman-Diamond syndrome is a rare genetic disorder of unknown pathogenesis involving exocrine pancreatic insufficiency and hematological and skeletal abnormalities. There is broad clinical variability; the extent of heterogeneity is unknown but comparisons within a large cohort of patients show no striking differences between patients of families with single or multiple affected offspring. Segregation analysis of a cohort of 69 families has suggested an autosomal recessive mode of inheritance. A single constitutional de novo chromosome rearrangement was reported in a Japanese patient involving a balanced translocation, t(6;12)(q16.2;q21.2), thereby suggesting possible loci for a genetic defect. Evenly spaced microsatellite markers spanning 26-32 cM intervals from D6S1056 to D6S304 and D12S375 to D12S346 were analyzed for linkage in members of 13 Shwachman-Diamond syndrome families with two or three affected children. Two-point lod scores were calculated for each marker under assumptions of recessive inheritance and complete penetrance. Negative lod scores indicated exclusion of both chromosome regions. Further, affected sibs were discordant for inheritance of chromosomes in most families based on constructed haplotypes. The cytogenetic abnormality is not associated with most cases of Shwachman-Diamond syndrome.

Postnatal development of the rat exocrine pancreas. I. Alterations in high- and low-affinity cholecystokinin receptors and enzyme secretion.

We tested the hypothesis that postnatal alterations in cholecystokinin (CCK) receptors are associated with developmental changes in enzyme secretory response. We used simultaneous measurements of CCK receptor binding and amylase release in pancreatic acini isolated from rat pups at various ages (1, 2, 5, 6, 18, and 36 days). CCK receptor binding was analyzed using the LIGAND program. The affinity of the high-affinity state increased postnatally at 18 and 36 days (p < 0.05); the capacity of the high-affinity state also increased at 2 days (p < 0.05), then declined sequentially up to 36 days. The affinity of the low-affinity state increased postnatally reaching statistical significance at 5 days; the capacity of the low-affinity state increased twofold at 2 days, reaching statistical significance at 5 days (p < 0.05); this was followed by a slight decrease at 36 days. At 1 day postnatally a small amylase response occurred (p < 0.05), but no dose-dependent response was observed. A significant CCK dose-dependent secretory response occurred at all other ages. Maximal amylase release was highest at 18 days (p < 0.05). CCK doses required to stimulate maximal amylase release were 20, 2, 1, 0.2 and 0.4 nM at 2, 5, 6, 18, and 36 days, respectively. The receptor occupancy rates for high- and low-affinity states decreased sequentially between 2 and 18 days of age, when maximal amylase release occurred. These data suggest that more spare receptors become available with increasing postnatal age. We conclude that postnatal alterations of both high- and low-affinity states of CCK receptors in pancreatic acini are associated with developmental changes in enzyme secretory response to CCK. An increase in the affinity of high-affinity state and the capacity of the low-affinity state may enhance acinar sensitivity to CCK.

Postnatal development of the rat exocrine pancreas. II. Effects of protein-calorie malnutrition on amylase secretion and CCK receptor binding.

Malnutrition induces pancreatic atrophy and intracellular derangement, but its effects on cholecystokinin (CCK) receptors and the CCK-induced secretory response remain unclear. We used a rodent model to study the developmental effects of protein-calorie malnutrition on exocrine pancreatic function. Simultaneous experiments evaluated postnatal alterations in CCK-induced amylase response and receptor binding of pancreatic acini. At all postnatal ages, somatic and pancreatic weight of the malnourished rats was significantly below age-matched controls (p < 0.01). The malnourished rats showed a higher secretory response to CCK at 1 day of age and increased acinar sensitivity at 2 days. Maximal amylase secretion was significantly higher at 5 and 18 days (p < 0.05), but remained similar to that of the age-matched controls at 36 days. CCK receptor binding showed no significant changes at 1 and 2 days postnatally in comparison with controls. At 5 and 18 days, the affinity of the high-affinity state showed a twofold increase, while the capacity of the high-affinity state decreased by 40-55%. At the same time, the affinity of the low-affinity state increased significantly (p < 0.05), but the capacity of the low-affinity state was essentially unchanged. The acinar sensitivity of malnourished rats was consistently reduced between 5 and 36 days, which coincided with a reduction in spare receptors in the malnourished rats. In conclusion, the increased amylase secretory response at 1 and 2 days of age may be due to an adaptive response of endocrine function to maternal metabolic stress. The increased affinities of CCK receptors at 5 and 18 days may be associated with a higher secretory responsiveness, while the decreased spare receptors may contribute to a reduction in the acinar sensitivity. These results demonstrate that malnutrition induces changes in CCK binding and its secretory response.

Biochemical tests in the diagnosis of chronic pancreatitis and in the evaluation of pancreatic insufficiency.

Chronic pancreatitis (adults) and cystic fibrosis (children) are the most common diseases leading to exocrine pancreatic insufficiency that, when reduced to < 5% of normal function, is characterised by steatorrhoea. The pathogenesis of the former condition is outlined, and recent concepts are emphasized. Biochemical tests to detect pancreatic insufficiency and to identify pancreatic disease as the cause of steatorrhoea include: serum enzyme tests (lipase, amylase, trypsin); stool chymotrypsin; isotopic tests based upon the assimilation of [14C] lipids and starch or excretion of the isotope as breath CO2, as well as the dual-labelled Schilling test; oral function tests utilising substrates hydrolysed by pancreatic enzymes such as benzoyl tyrosyl-p-aminobenzoic acid and fluorescein dilaurate; and duodenal intubation studies following meal-induced or hormonal stimulation of the pancreas. The rationale for these tests and the cumulative clinical experience of their utility are reviewed. A recommended diagnostic strategy is briefly presented. The role of various biochemical procedures to evaluate the efficacy of pancreatic enzyme replacement therapy is also described.

Stool chymotrypsin activity measured by a spectrophotometric procedure to identify pancreatic disease in infants.

The aim of this study was to assess the analytical performance of the BMC stool chymotrypsin test and its accuracy in diagnosing pancreatic disease in infants. The test utilizes a detergent which solubilizes chymotrypsin bound to stool residues, and a tetrapeptide coupled to p-nitroaniline which is specifically cleaved by chymotrypsin. We employed the IL Multistat at 30 degrees C to monitor enzyme activity as an increase in absorbance at 405 nm. The reaction was linear to 600 U/g stool. Recovery of exogenous chymotrypsin with a single detergent extraction was 98-105%, and of endogenous chymotrypsin (as determined by multiple extractions) 80-97%. Imprecision (CV) was 2.2% within-day and 2.4% between-day for the BMC control, and 2.4-5.2% for stool chymotrypsin in the range 8.3-14.4 U/g. Since the test utilises only 100 mg of stool, inhomogeneity of enzyme distribution was assessed by multiple assays on a single stool, which revealed a range of activity from 4.2-150%. We therefore recommend sampling of each stool in triplicate. With this procedure, chymotrypsin was measured in 220 consecutive stool samples submitted for fat determination from children. Applying the manufacturer's lower reference limit of 4.1 U/g, the following results were obtained (number abnormal/total number): suspected intestinal disease with normal stool fat (5/127); proven intestinal disease and increased stool fat (1/26); untreated cystic fibrosis (CF) with (19/22), and without (0/3) steatorrhea; CF with pancreatic insufficiency on replacement therapy (4/42).(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormalities of circulating immunoreactive pancreatic anionic trypsinogen in cystic fibrosis: an assay artifact due to cross-reacting serum antibodies.

In patients with CF, serum pancreatic cationic trypsinogen has proven to be useful for newborn diagnostic screening and also as a test of pancreatic function in the older patient. However, an assay for serum anionic trypsinogen is of no value as a test of pancreatic function in CF due to an apparent artifactual elevation of this enzyme in some patients. In this study, we evaluated the extent of the abnormality in the anionic trypsinogen assay and also elucidated the nature of the interfering material. CF patients were grouped according to the presence (pancreatic insufficiency) or absence (pancreatic sufficiency) of steatorrhea. In CF infants, both serum cationic and anionic trypsinogen levels were greatly elevated. Serum cationic trypsinogen declined with age in patients with pancreatic insufficiency, reaching low or undetectable levels after 6 years. In contrast, serum anionic trypsinogen levels remained normal or elevated in 33% of those over 6 years of age. There was no age-related change in either cationic or anionic trypsinogen among the CF patients with pancreatic sufficiency, and the majority had normal or elevated levels. Serum samples from selected CF patients were separated into IgG and non-IgG fractions using Staph. Protein A columns. Immunoreactive cationic and anionic trypsinogen were detectable in the non-IgG fractions of sera from CF infants and older patients with pancreatic sufficiency. In older CF patients with undetectable serum cationic and anionic trypsinogen, no immunoreactive material was detectable in either the IgG or non-IgG fractions.(ABSTRACT TRUNCATED AT 250 WORDS)

Glycine conjugation of para-aminobenzoic acid (PABA): a quantitative test of liver function.

OBJECTIVE: To evaluate glycine conjugation of para-aminobenzoic acid (PABA) to the hippurated metabolites, para-aminohippuric acid (PAHA), and para-acetamidohippuric acid (PAAHA) as a quantitative liver function test in patients with liver disease. DESIGN AND METHODS: Serum concentrations of PABA and metabolites were measured by high pressure liquid chromatography in 24 controls and 50 patients with hepatobiliary disease. RESULTS: Hippurate formation was significantly decreased in all patient groups with chronic liver disease versus controls. The hippurate ratio (% hippurated metabolites formed) correlated with severity of disease, serum albumin, and factor VII concentrations. PAHA concentration was a better prognostic indicator than factor VII concentrations in patients with acute liver disease; concentrations of zero correctly predicted a poor outcome in patients with fulminant liver failure. CONCLUSIONS: Glycine conjugation of PABA may be useful as a quantitative liver function test in patients with hepatobiliary disease and as a prognostic index in patients with fulminant liver failure.

Pancreatic aspects of cystic fibrosis and other inherited causes of pancreatic dysfunction.

Causes of pancreatic dysfunction in childhood can be divided into two general categories: (1) hereditary conditions that directly affect the pancreas and (2) acquired disorders in which loss of pancreatic function is a secondary phenomenon. This article discusses genotypes and phenotypes, clinical features, Shwachman-Diamond syndrome, isolated enzyme deficiencies, and other topics.

Pathogenesis of malnutrition in cystic fibrosis, and its treatment.

PATHOGENESIS: We have developed a model of the pathogenesis of malnutrition in cystic fibrosis. It consists of the relationship between nutrient balance and nutrient requirement. The validation has been conducted with respect to energy, but the same general principals can be applied to any nutrient. A patient with CF either loses weight or fails to grow normally if their absorbed energy intake is less than their total daily energy expenditure. Multiple factors have the potential to contribute to reduced energy intake including, anorexia, gastroeosophageal (GE) reflux leading to vomiting and hence food loss, as well as maldigestion. Another more recently recognized source of energy loss, is glucosuria as a result of CF related diabetes (CFRD). Conversely, lung inflammation appears to be related to increases in resting metabolic rate (RMR). Acute exacerbations of the chronic lung disease increases RMR which returns to a basal level some weeks after the inflammation is treated. In clinically stable patients with CF, RMR rises in a quadratic fashion as lung function falls. When FEV(1)is >85% predicted RMR is not different from controls, but it rises in a curvilinear fashion as FEV(1)falls. Initially it appears that patients adapt to their increased RMR by reducing their activity so their total daily energy expenditure (TDEE) is often no higher than controls. But this is by no means always the case. Furthermore good lung care requires CF patients to be involved in aerobic activities, hence their TDEE would rise. Although there has been considerable interest as to whether the genetic defect has an energy wasting effect, it appears genetic factors have little or no effect on RMR. TREATMENT: This starts with making an energy diagnosis. First, a 3 day faecal fat balance study is conducted. This provides information with regard to intake as well as to maldigestion. In addition a history of GE reflux is sought, since it can readily be treated with H(2)-blockers. If significant fat malabsorption exists, efforts are made to improve pancreatic enzyme dose and function. The possibility of CFRD also needs to be considered. We measure the RMR of the patient using open circuit indirect calorimetry. Recommendations for diet therapy are based on estimated TDEE, which is determined from RMR taking into account faecal losses. Diet therapy places the emphasis on increasing the fat content of the diet. We have conducted a study to determine whether or not oral supplements help increase TDEE and they did not; they merely replaced food energy. Conversely, nocturnal gastrostomy supplemental feeding, while reducing voluntary food energy intake by about 20%, does result in a significant increase in total daily energy intake. Our target is to achieve a completely normal nutritional status. Long term follow-up of these patients has shown significantly better survival in patients who achieve normal nutritional status. The advent of lung transplantation has added another dimension. In our experience, following a successful lung transplant, most patients no longer need their supplemental gastrostomy feeding. SUMMARY: Our clinic policy is to encourage a high fat diet (35-40% total energy) and our patients grow normally in height and weight until their lung disease deteriorates significantly. Patients who develop a negative energy balance seldom if ever respond to diet therapy and hence are candidates for supplemental nocturnal gastrostomy feeds. Gastrostomy fed patients constitute 3 to 5% of our total CF population of approximately 590 patients.

Challenges in the dietary treatment of cystic fibrosis related diabetes mellitus.

Cystic fibrosis related diabetes mellitus is an increasingly recognized problem as survival in patients with cystic fibrosis improves. In a 5 year retrospective study of 627 children and adults attending Toronto cystic fibrosis clinics, we identified 57 (9%) patients with cystic fibrosis related diabetes mellitus; four (1.3%) of 301 children (<18 years) and 53 (16%) of 326 adults. The development of this complication of cystic fibrosis is associated with increased mortality, deteriorations in both respiratory and nutritional status, and the development of late microvascular, but not macrovascular, diabetic complications. Unfortunately, systematic review of the literature provides few well designed studies that provide sound evidence for clinical practice. Recommendations are therefore often based on anecdote, rather than physiological or outcomes research. Dietary therapy combines the principles of the dietary management of both cystic fibrosis and diabetes mellitus, but emphasizes the need for a high energy diet (> 100% of recommended daily intake) in patients with cystic fibrosis related diabetes mellitus. The importance of calories from fat is emphasized, with no restriction on total carbohydrate intake. Insulin intake mirrors carbohydrate intake. Routine dietary therapy is straightforward, but challenges occur due to both complications of cystic fibrosis and advancing disease. If a patient with cystic fibrosis related diabetes mellitus is malnourished, overnight enteral tube feeding is often used, with an adjusted insulin regimen. There is a great need for both physiological and outcomes research to provide sound scientific evidence for the dietary treatment of cystic fibrosis related diabetes mellitus.

Inherited causes of exocrine pancreatic dysfunction.

The exocrine pancreas is functionally immature at birth. Protease function is probably adequate, but lipase activity approximates 5% to 10% of adult values in the newborn and remains low in infancy. Pancreatic amylase secretion is essentially absent at birth and remains low through the first years of life. Functional disturbances of the exocrine pancreas are less frequent in childhood than in adult life. Causes of pancreatic dysfunction in childhood can be divided in two general categories: hereditary conditions, which directly affect the pancreas; and acquired disorders, in which loss of pancreatic function is a secondary phenomenon. Most inherited causes of pancreatic dysfunction are due to a generalized disorder. Cystic fibrosis is, by far, the most common inherited cause of disturbed pancreatic function among Caucasian children. All other inherited causes of exocrine pancreatic dysfunction (eg, Johanson-Blizzard syndrome) are uncommon or rare.

Pathophysiology of the pancreas in cystic fibrosis.

Pancreatic insufficiency occurs in the majority of cystic fibrosis (CF) patients. Deficient fluid secretion is apparent at all levels of pancreatic function and leads to pancreatic protein hypersecretion which may in turn result in protein precipitation and ductal plugging. An impaired chloride and bicarbonate secretion appears to account for this fluid secretion deficit. A minority of CF patients have sufficient preservation of pancreatic function to prevent steatorrhoea. These patients are diagnosed at a later age, experience milder symptoms and have a far superior overall prognosis than patients with pancreatic insufficiency (PI). Patients who are homozygous for delta F508 have a high frequency of PI (99%), whereas patients with other genotypes are more often pancreatic sufficient (PS). In 538 patients with CF DNA analysis was performed and related with pancreatic function. The most striking observation was that nearly all given genotypes were associated with either PI or PS and not with both. In addition, we were able to classify mutations as "severe" and "mild" with respect to pancreatic function.

Chronic intussusception due to antral myoepithelioma.

Intussusception was seen on abdominal sonography and computed tomography in a 15-year-old boy who presented with a 6-week history of weight loss, vomiting, abdominal pain, abdominal mass, and hyperamylasemia. Laparotomy revealed a chronic gastroduodenal intussusception, the lead point of which was an antral myoepithelioma, a rare entity in this age group.