Semi-automated software improves interrater reliability and reduces processing time of magnetic resonance imaging-based exocrine pancreatic assessments in pediatric patients.

OBJECTIVES: Magnetic resonance (MR) imaging with secretin stimulation (MR-PFTs) is a non-invasive test for pancreatic exocrine function based on assessing the volume of secreted bowel fluid in vivo. Adoption of this methodology in clinical care and research is largely limited to qualitative assessment of secretion as current methods for secretory response quantification require manual thresholding and segmentation of MR images, which can be time-consuming and prone to interrater variability. We describe novel software (PFTquant) that preprocesses and thresholds MR images, performs heuristic detection of non-bowel fluid objects, and provides the user with intuitive semi-automated tools to segment and quantify bowel fluid in a fast and robust manner. We evaluate the performance of this software on a retrospective set of clinical MRIs. METHODS: Twenty MRIs performed in children (< 18 years) were processed independently by two observers using a manual technique and using PFTquant. Interrater agreement in measured secreted fluid volume was compared using intraclass correlation coefficients, Bland-Altman difference analysis, and Dice similarity coefficients. RESULTS: Interrater reliability of measured bowel fluid secretion using PFTquant was 0.90 (0.76-0.96 95% C.I.) with - 4.5 mL mean difference (-39.4-30.4 mL 95% limits of agreement) compared to 0.69 (0.36-0.86 95% C.I.) with - 0.9 mL mean difference (-77.3-75.5 mL 95% limits of agreement) for manual processing. Dice similarity coefficients were better using PFTquant (0.88 +/- 0.06) compared to manual processing (0.85 +/- 0.10) but not significantly (p = 0.11). Time to process was significantly (p < 0.001) faster using PFTquant (412 +/- 177 s) compared to manual processing (645 +/- 305 s). CONCLUSION: Novel software provides fast, reliable quantification of secreted fluid volume in children undergoing MR-PFTs. Use of the novel software could facilitate wider adoption of quantitative MR-PFTs in clinical care and research.

Aplicación de un método de mejora continua para la selección de los marcadores diagnóstico de pancreatitis aguda en un servicio de urgencias / Application of a continual improvement approach to selecting diagnostic markers for acute pancreatitis in an emergency department

Objetivo: Aplicar un ciclo de mejora continua (CMC) para la determinación de un algoritmo de solicitud de pruebas de laboratorio en el diagnóstico de la pancreatitis aguda (PA) en un servicio urgencias hospitalario (SUH). Método: Estudio cuasiexperimental que aplicó la metodología CMC en dos fase consecutivas en pacientes atendidos en un SUH: en la primera se usaron la amilasa y lipasa para el diagnóstico de PA, y en la segunda solo la lipasa y solo si esta estaba en un rango determinado, se añadía automáticamente la amilasa. Se recogieron datos demográficos, número y valores de amilasa y lipasa, el diagnóstico final, y se realizó una encuesta de satisfacción a los médicos de urgencias. Resultados: El primer ciclo incluyó 517 pacientes, 20 de ellos con PA. Las características de las pruebas diagnósticas fueron: amilasa [sensibilidad (Se): 0,70; especificidad (Es): 0,85; cociente de probabilidad positivo (CPP): 17 y cociente de probabilidad negativo (CPN): 0,31], lipasa (Se: 0,85; Es: 0,96; CPP: 21 y CPN: 0,16) y la determinación de ambas (Se: 0,85; Es: 0,99; CPP: 85 y CPN: 0,15). En el segundo ciclo se incluyeron 4.815 pacientes, de los cuales 118 sufrieron una PA. El nuevo algoritmo propuesto tuvo una Se: 0,92; Es: 0,98; CPP: 46 y CPN: 0,08. Conclusiones: La elaboración de un protocolo de solicitud de marcadores de laboratorio y la estrategia secuencial de solicitud de enzimas pancreáticas pueden ser efectivas para diagnosticar PA en un SUH (AU)

Objective: To apply a continual improvement model to develop an algorithm for ordering laboratory tests to diagnose acute pancreatitis in a hospital emergency department. Methods: Quasi-experimental study using the continual improvement model (plan, do, check, adjust cycles) in 2 consecutive phases in emergency patients: amylase and lipase results were used to diagnose acute pancreatitis in the first phase; in the second, only lipase level was first determined; amylase testing was then ordered only if the lipase level fell within a certain range. We collected demographic data, number amylase and lipase tests ordered and the findings, final diagnosis, and the results of a questionnaire to evaluate satisfaction with emergency care. Results: The first phase included 517 patients, of whom 20 had acute pancreatitis. For amylase testing sensitivity was 0.70; specificity, 0.85; positive predictive value (PPV), 17; and negative predictive value (NPV), 0.31. For lipase testing these values were sensitivity, 0.85; specificity, 0.96; PPV, 21, and NPV, 0.16. When both tests were done, sensitivity was 0.85; specificity 0.99; PPV, 85; and NPV, 0.15. The second phase included data for 4815 patients, 118 of whom had acute pancreatitis. The measures of diagnostic yield for the new algorithm were sensitivity, 0.92; specificity, 0.98; PPV, 46; and NPV, 0.08]. Conclusion: This study demonstrates a process for developing a protocol to guide laboratory testing in acute pancreatitis in the hospital emergency department. The proposed sequence of testing for pancreatic enzyme levels can be effective for diagnosing acute pancreatitis in patients with abdominal pain (AU)

Endoscopic ultrasound in the diagnosis of chronic pancreatitis

Diagnosis of chronic pancreatitis (CP) remains a challenge. Endoscopic ultrasound (EUS) can be considered nowadays as the technique of choice for the morphological diagnosis of this disease. More than three or four EUS defined criteria of CP need to be present for the diagnosis of the disease. The development of the more restrictive Rosemont classification aims to standardize the criteria, assigning different values to different features but its impact on the EUS-based diagnosis of CP is debatable. A combined use of endoscopic function test and EUS has even increased the diagnostic yield. Elastography and FNA may be also of help for diagnosing CP. EUS also provides with very valuable information on the severity of the disease, giving key information that may influence in the treatment. Differential diagnosis of solid pancreatic masses in the context of a CP is also challenging, EUS plays a key role in this context. It provides with the possibility of obtaining specimens for histopathological diagnosis. Nowadays, new developed techniques associated to EUS, like elastography and contrast enhancement, are also showing promising results for the differentiating between these pancreatic lesions (AU)

No disponible

Elevación de enzimas pancreáticas y edema facial. Síndrome de DRESS / Elevation of pancreatic enzymes and facial edema. DRESS syndrome

No disponible

Pancreatitis aguda como complicación fatal de la quimioembolización de un carcinoma hepatocelular / Acute pancreatitis as fatal complication after chemoembolization of hepatocellular carcinoma

No disponible

Efecto de la necrosectomía y el sistema de cierre asistido al vacío (VAC) sobre función mitocondrial y marcadores de estrés oxidativo en pancreatitis aguda severa / Effect of necrosectomy and vacuum-assisted closure (VAC) on mitochondrial function and oxidative stress markers in severe acute pancreatitis

Antecedentes: la pancreatitis aguda severa (PAS) se asocia con alta morbilidad y mortalidad. Objetivo: evaluar si la necrosectomía sola o necrosectomía + el sistema de cierre al vacío (VAC), ofrece efectos favorables adicionales en la función mitocondrial y/o marcadores de estrés oxidativo en PAS. Métodos: mediante un estudio observacional prospectivo, se incluyeron pacientes con PAS y APACHE II > 8 sin respuesta satisfactoria al manejo en la Unidad de Cuidados Intensivos. Dieciséis pacientes se sometieron a necrosectomía y 24 a necrosectomía + VAC cada 48 h. Se dividieron en sobrevivientes y fallecidos. Se determinó la fluidez de la membrana submitocondrial de las plaquetas y la hidrólisis de la F0F1-ATPasa como función mitocondrial. El estrés oxidativo/nitrosativo se midió mediante lipoperóxidos (LPO), óxido nítrico (ON), fluidez de la membrana de eritrocitos y capacidad antioxidante total (CAT). Resultados: la fluidez de membrana de partículas submitocondriales de plaquetas se mantuvo incrementada significativamente durante todo el estudio y aumentó al final en los fallecidos tratados con necrosectomía + VAC vs. los sobrevivientes (p < 0,041). La hidrólisis se encontró significativamente elevada desde el inicio hasta el final en todos los pacientes, predominando en los que fallecieron tratados con necrosectomía (p < 0,03). Hubo aumento de LPO en todos los pacientes aunque la necrosectomía fue más eficaz en la disminución al final en sobrevivientes (p < 0,039). El ON se encontró incrementado durante el resultado basal-final en sobrevivientes y fallecidos en ambas alternativas de tratamiento. La fluidez de la membrana de eritrocitos se encontró incrementada en los sobrevivientes tratados con necrosectomía + VAC y se normalizó al final (p < 0,045). La CAT se encontró consumida en todos los pacientes durante todo el estudio. Conclusiones: se encontró disfunción mitocondrial y estrés oxidativo/nitrosativo con consumo importante de los antioxidantes sistémicos. La necrosectomía fue más eficiente al eliminar mejor los LPO. La necrosectomía + VAC mejoró la fluidez de la membrana de eritrocitos e incrementó la sobrevida (AU)

Background: Severe acute pancreatitis (SAP) is associated with high morbidity and mortality. Objective: To evaluate whether necrosectomy, alone or combined with vacuum-assisted closure (VAC), has any additional beneficial effects on mitochondrial function and/or oxidative stress markers in SAP. Methods: Patients with SAP, APACHE II score > 8, and inadequate response to management in an intensive care unit were included in a prospective observational study. Sixteen underwent necrosectomy and 24 underwent necrosectomy plus VAC every 48 h. Patients were then categorized as survivors or deceased. Submitochondrial membrane fluidity of platelets and F0F1-ATPase hydrolysis were measured to represent mitochondrial function. Oxidative/nitrosative stress was measured using lipoperoxides (LPOs), nitric oxide (NO), erythrocyte membrane fluidity, and total antioxidant capacity (TAC). Results: Membrane fluidity in submitochondrial particles of platelets remained significantly increased throughout the study, and then eventually rised in deceased patients managed with necrosectomy + VAC vs. survivors (p < 0.041). Hydrolysis was significantly increased from baseline to endpoint in all patients, predominating in those who died after management with necrosectomy (p < 0.03). LPO increased in all patients, and necrosectomy was more efficient for the eventual decrease in survivors (p < 0.039). NO was found to be increased for the baseline-endpoint result among both survivors and deceased patients with both management options. Erythrocyte membrane fluidity was increased in survivors managed with necrosectomy + VAC, and eventually returned to normal (p < 0.045). TAC was found to be consumed in all patients for the duration of the study. Conclusions: Mitochondrial dysfunction and oxidative/ nitrosative stress with significant systemic antioxidant consumption were found. Necrosectomy was more efficient and better cleared LPOs. Necrosectomy + VAC improved erythrocyte membrane fluidity and increased survival (AU)

Célula beta, diabetes y la ruta de hypoxia inducible factor / Hypoxia signalling in beta cell function and diabetes

Las células responden a niveles bajos de oxígeno (hipoxia) activando un programa génico específico para potenciar la adaptación al metabolismo anaeróbico y promover la conservación de la energía. Los factores de transcripción HIF (del inglés hypoxia inducible factor) juegan un papel central en la respuesta a hipoxia. La actividad de HIF está regulada por el gen supresor de tumores VHL, que degrada a HIF en presencia de oxígeno. Recientemente varios estudios han puesto de manifiesto la importancia de la ruta de respuesta a hipoxia HIF en la homeostasis de la glucosa. Cambios en los niveles de actividad de esta ruta en la célula beta endocrina alteran la capacidad de secreción de insulina. Además, la ruta de respuesta a hipoxia HIF parece regular la función metabólica de órganos implicados en la patogénesis de la diabetes y el síndrome metabólico como el hígado, el tejido adiposo y el músculo. Estas observaciones sugieren la posibilidad de que alteraciones en la ruta de hipoxia HIF puedan contribuir al desarrollo de diabetes

Under low oxygen pressure (hypoxia), cells activate a specific genetic program, modulating genes involved in anaerobic metabolism and cellular energy metabolism. The transcriptional hypoxia inducible factors (HIFs) are central to this response. HIF activity is regulated by the von Hippel-Lindau tumour suppressor protein (pVHL). In the presence of oxygen, pVHL targets HIF for ubiquitination and subsequent proteasomal degradation. Several recent reports have revealed a critical role of the hypoxia response mediated by HIF on glucose homeostasis. Changes in HIF pathway activity in beta-cells impair insulin secretion. Furthermore, the HIF pathway regulates the metabolic function in organs involved in the pathogenesis of diabetes and metabolic syndrome such as liver, fat and muscle. These observations raise the question of whether changes in HIF levels might contribute to the progression of type 2 diabetes

Insuficiência exócrina do pâncreas: etiologias / Exocrine pancreatic insufficiency: etiology

Insuficiência exócrina do pâncreas tem sido revisitada em vários compêndios médicos internacionais e suas novas etiologias avaliadas e reconfirmadas. Neste artigo abordamos as causas mais comuns e tradicionais, pancreatite crônica e fibrose cística, bem como as recentemente mais enfatizadas como doença celíaca e diabetes mellitus. Comentamos a clínica e o diagnóstico precoce e o tratamento com reposição enzimática

Pancreatic exocrine insufficiency has been broadly discussed in international medical literature. New aetiologies have been studied and reaffirmed. In this paper we describe common and traditional causes such as chronic pancreatitis and cystic fibrosis as well as the most recently emphasised celiac disease and diabetes. We also review clinical features, early diagnosis and pancreatic enzyme replacement therapy

Función pancreática exocrina en diabetes mellitus: Determinación de elastasa fecal / Pancreatic exocrine function in diabetes mellitus: Determination of fecal elastase

Background: One of the complications of diabetes mellitus is the development of pancreatic exocrine insufficiency. Aim: To study pancreatic exocrine function in diabetics patients. Material and methods: Seventy two diabetic patients were included in the protocol, but two were withdrawn because an abdominal CAT scan showed a chronic calcified pancreatitis, previously undiagnosed. Fecal elastase was measured by ELISA and the presence of fat in feces was assessed using the steatocrit. Results: Mean age was 60±12 years and 67 (96%) patients had a type 2 diabetes. Fecal elastase was normal (elastase >200 µg/g) in 47 (67%) patients, mildly decreased (100-200 µg/g) in 10 (14%) and severely decreased in 13 (19%). There was a significant association between elastase levels and time of evolution of diabetes (p=0.049) and between lower elastase levels and the presence of a positive steatocrit (p=0.042). No significant association was found between elastase levels and other chronic complications of diabetes such as retinopathy, nephropathy, neuropathy, microangiopathy or with insulin requirement. Conclusions: One third of this group of diabetic patients had decreased levels of fecal elastase, that was associated with the time of evolution of diabetes. Patients with lower levels of elastase have significantly more steatorrhea. Among diabetics it is possible to find a group of patients with non diagnosed chronic pancreatitis.

Nutrición en el enfermo con fibrosis quística / Nutrition in the cystic fibrosis patient

La fibrosis quística es una enfermedad que se asocia a una mutación de un gen localizado en el brazo largo del cromosoma 7. Esta enfermedad multisistémica afecta especialmente a los pulmones y al páncreas exocrino, lo cual supone el trastorno más influyente en la nutrición de estos pacientes. Generalmente, la suplementación con enzimas pancreáticas es necesaria como elemento terapéutico. La prevalencia de diabetes en esta enfermedad aumenta con la edad, mientras que la afectación hepática clínica es menos frecuente y otras complicaciones intestinales como el ileomeconial, el reflujo gastroesofágico o la obstrucción del intestino distal pueden condicionar también la malnutrición. La prevalencia de la desnutrición en los pacientes con fibrosis quística es elevada, aunque variable, y se asocia directamente con el estado pulmonar y la supervivencia. La terapia nutricional ha adquirido gran importancia ya que se asocia con un mejor crecimiento y mejora o estabilización de la función pulmonar, por lo que debe ser una parte integral del tratamiento de estos pacientes (AU)

Cystic fibrosis is a disease that has been associated with a genetic mutation, affecting a single gene on the long arm of chromosome 7. This multisystemic disease particulary affects the lungs and exocrine pancreas, which is the most influential disorder in the nutrition of these patients. Generally, a supplementation therapy with pancreatic enzymes is necessary. The prevalence of diabetes in this disease increases with age, while clinical liver impairement is less frequent and other complications such as intestinal ileomeconial, gastroesophageal reflux or distal bowel obstruction can also affect malnutrition. The prevalence of malnutrition incystic fibrosis patients is high, although variable be ingdirectly associated with both pulmonary status and survival. Nutritional support has become very important and it is associated with better growth and improvement or stabilization of lung function, so it must be an integral part of treatment of these patients (AU)

En paciente con dolor abdominal e historia de ingesta alcohólica elevada, ¿qué pruebas permiten confirmar o descartar la existencia de una pancreatitis crónica? / In patients with abdominal pain and a history of high alcoholin take, which tests allow the presence of chronic pancreatitis to be confirmedor excluded?

No disponible

No disponible

Neoplasias de páncreas y periampulares: morbimortalidad, resultados funcionales y supervivencia a largo plazo / Pancreatic and periampullary tumors: Morbidity, mortality, functional results and long-term survival

Objetivos Evaluar la morbimortalidad postoperatoria, el estado funcional y la supervivencia a largo plazo de pacientes con tumores de páncreas o periampulares a los que se intervino quirúrgicamente. Pacientes y métodos Cohorte de 160 pacientes a los que se intervino consecutivamente: 80 duodenopancreatectomías cefálicas (DPC), 30 resecciones corporocaudales (RCC), 7 duodenopancreatectomías totales, 4 resecciones centrales y 3 ampulectomías; en 36 pacientes no se realizó resección. La función pancreática se evaluó mediante test de sobrecarga oral a la glucosa, grasas en heces y elastasa fecal. Resultados La tasa de resecabilidad fue del 77,5%. En los pacientes resecados (n = 124) la morbilidad fue del 38,7% (con una tasa de fístulas pancreáticas del 6,4%) y la mortalidad del 4%. En las DPC la función endocrina pancreática ha empeorado en el 41%, con esteatorrea en el 58,6% de los casos; en las RCC estos valores fueron del 53,6 y del 21,7%. En los 36 pacientes no resecados la morbilidad fue del 27,7% y la mortalidad del 8,3%. La supervivencia a 2 a 5 años en los pacientes resecados por adenocarcinoma ductal fue del 42 y del 9%; en los ampulomas del 71 y del 53%; en los adenocarcinomas mucinosos, del 83 y del 33%; en los adenocarcinomas duodenales, del 100 y del 75%, y en el colangiocarcinoma distal, del 50 y del 50%.ConclusionesLa morbilidad de la cirugía resectiva pancreática continúa siendo alta, aunque la mortalidad perioperatoria es baja. Las alteraciones de la función exocrina y endocrina son muy frecuentes y dependen del tipo de resección. A pesar de estar gravada con frecuentes complicaciones y alteraciones funcionales, la cirugía resectiva ofrece una posibilidad de supervivencia a largo plazo en determinados casos (AU)

Aims To evaluate postoperative morbidity and mortality, pancreatic function and long-term survival in patients with surgically treated pancreatic or periampullar tumours. Patients and methods Cohort study including 160 patients consecutively operated on: 80 pancreaticoduodenectomies (PD), 30 distal pancreatectomies (DP), 7 total pancreatectomies, 4 central pancreatic resections and 3 ampullectomies. The tumour was not resected in 36 patients. Pancreatic function was evaluated by oral glucose tolerance test, faecal fat excretion and elastase. Results Resectability rate was 77.5%. In resected patients (n=124), 38.7% had complications with a pancreatic fistula rate of 6.4% and a mortality rate of 4%. In PD, endocrine function worsened in 41% and 58.6% had steatorrhoea; these figures in DP were 53.6% and 21.7% respectively. In the 36 non-resected patients, postoperative morbidity was 27.7% and mortality 8.3%. Two and five-year survival rates in resected patients with pancreatic cancer were 42% and 9% respectively; in malignant ampulloma 71% and 53%; in mucinous adenocarcinomas 83% and 33%; in duodenal adenocarcinoma 100% and 75%; and in distal cholangiocarcinoma 50% and 50%.ConclusionsMorbidity associated with resective pancreatic surgery is still high, but perioperative mortality is low. Endocrine and exocrine disturbances are very common depending on the type of resection. Despite the associated morbidity and functional disorders, surgery provides long-term survival in selected cases (AU)

Pancreatitis crónica: controversias respecto a la etiología, el diagnóstico y el tratamiento / Chronic pancreatitis: controversies in etiology, diagnosis and treatment

La patogenia de la pancreatitis crónica idiopática sigue siendo poco conocida, a pesar de las expectativas de atribuir el daño pancreático que sufren los pacientes con esta enfermedad a factores genéticos. Las mutaciones del gen del tripsinógeno catiónico, del gen del inhibidor de la tripsina secretoria del páncreas y del gen regulador de conductancia de la fibrosis quística no explican la pancreatitis crónica de la mayoría de los pacientes con pancreatitis crónica idiopática. La mejor forma de diagnosticar una pancreatitis crónica de conductos pequeños es la prueba de estimulación hormonal. La ecografía endoscópica puede detectar anomalías tanto en el parénquima como en los conductos del páncreas. El verdadero valor de la ecoendoscopia en el diagnóstico de la pancreatitis crónica de conductos pequeños está aún por determinar y se está investigando activamente. No está claro si la ecografía endoscópica es más sensible a los cambios estructurales precoces de los pacientes con afectación de conductos pequeños o si sobrediagnostica la pancreatitis crónica. Los suplementos de enzimas pancreáticas de formulación no entérica, junto con la supresión ácida (bloqueadores H2 o inhibidores de la bomba de protones), constituyen un tratamiento eficaz del dolor en los pacientes con pancreatitis crónica de conductos pequeños. El papel del bloqueo del plexo celiaco guiado por ecografía endoscópica debe limitarse al tratamiento de aquellos pacientes con pancreatitis crónica cuyo dolor no responda a otras modalidades. Parece que la pancreatectomía total seguida de autotrasplante autólogo de células de los islotes podría representar un posible abordaje terapéutico, pero debe considerarse experimental por ahora (AU)

Usefulness of Intraductal Secretin Test in Assessing Exocrine Pancreatic Function in Patients with Chronic Pancreatitis / 대한소화기내시경학회지

BACKGROUND/AIMS: The duodenal intubation test (duodenal secretin test; DST) is now considered the 'gold standard' test of exocrine pancreatic function in detecting exocrine pancreatic dysfunction in patients with chronic pancreatitis. However, the DST has not been widely used, because it is time-consuming, invasive, and labor-intensive. On the other hand, intraductal secretin test (IDST) with endoscopic retrograde cannulation of the main pancreatic duct has been showed similar diagnostic efficiency compared with DST. We assessed the clinical usefulness of IDST and investigated parameters for assessing impaired pancreatic function of IDST. METHODS: Pure pancreatic juices were collected from 12 patients with chronic pancreatitis by endoscopic cannulation after a bolus intravenous injection of secretin 100 U, for 15min in three 5-min intervals. Five parameters of IDST were measured, and the sensitivity, specificity, and accuracy of IDST evaluated compared with ERP. RESULTS: When we regarded mean-1.5 SD as the lower limits of IDST, the diagnostic sensitivity, specificity, and accuracy of five parameters to detect chronic pancreatitis were 91.7-100%, 75-87.5%, and 85-90%, respectively. Among five parameters, pancreatic juice secretory volume, bicarbonate concentration, and amylase output showed the highest diagnostic accuracy, followed by lipase output and bicarbonate output. A 10-min collection showed as much information as a 15-min collection. CONCLUSIONS: 10-min intraductal secretin test is useful as the conventional exocrine pancreatic function test in detecting exocrine pancreatic dysfunction in patients with chronic pancreatitis and the most discriminatory parameters are pancreatic juice secretory volume, bicarbonate concentration, and amylase output.

The Clinical Usefulness of Fecal Elastase-1 Test as an Exocrine Pancreatic Function Test for the Diagnosis of Chronic Pancreatitis / 대한소화기내시경학회지

BACKGROUND/AIMS: The quantitative analysis of fecal elastase-1 has been proposed as a noninvasive test for the examination of pancreatic exocrine function. Therefore, we evaluated the diagnostic value of fecal elastase-1 by comparing with endoscopic intraductal secretin test (IDST) which is used as a direct exocrine function test for the diagnosis of chronic pancreatitis. METHODS: Fecal elastase-1 concentrations were measured by ELISA in spot stool samples of 40 healthy control subjects, 21 patients with liver disease, and 12 patients with chronic pancreatitis diagnosed with endoscopic retrograde cholangiopancreatography (ERCP) and IDST. Chronic pancreatitis were then sub-classified into mild (I), moderate (II) and severe form (III), using the Cambridge classification according to ERCP finding. The linear regression analysis to evaluate the correlation between the concentration of fecal elastase-1 and IDST was performed during ERCP. The cut-off value of fecal elastase-1 to discriminate chronic pancreatitis was calculated based on receiver operating characteristic curve, and the clinical usefulness of fecal elastase-1 in the diagnosis of chronic pancreatitis was evaluated. RESULTS: There were several significant correlations between fecal elastase-1 and various parameters of IDST: pancreatic juice secretory volume (r=0.797, p<0.002), bicarbonate concentration (r=0.846, p<0.001), elastase-1 concentration in pancreatic juice (r=0.671, p<0.017), and amylase output (r=0.783, p<0.003). The mean value of fecal elastase-1 concentration in the patients with chronic pancreatitis (197+/-77microgram/g stool) was significantly lower than those in the healthy control subjects (815+/-133microgram/g stool) and patients with liver disease (594+/-206microgram/g stool) (p<0.05). The cutoff value of fecal elastase-1 to discriminate between the healthy control and chronic pancreatitis patients was 201microgram/g stool. With this cutoff value, the accuracy, sensitivity, and specificity of fecal elastase-1 to diagnose chronic pancreatitis were 78.8%, 67.7%, and 82.5%, respectively, compared to the morphological severity (the sensitivity of mild, moderate, and severe chronic pancreatitis was 33.3%, 66.7%, 83.3%, respectively). CONCLUSIONS: Measurement of fecal elastase-1 is a reliable and sensitive non-invasive test for the diagnosis of moderate to severe forms of chronic pancreatitis.

Pancreatitis

Pancreatic inflammatory disease may be classified as acute pancreatitis(AP) and chronic pancreatitis(CP) by primarily clinical criteria, with the obvious difference between them being restoration of normal function in the former and permanent residual damage in the latter. Gallstones and alcohol are the most common causes of acute pancreatitis. Abdominal pain is the major symptom. The diagnosis of AP is usually established by the presence of an increased serum amylase and lipase. CT scanning is the imaging method of choice in determining the severity and complications of AP. There are no generally recognized specific treatments for AP. Supportive therapy, which includes vigorous intravenous hydration, ample analgesia, and vascular, respiratory, and renal support as needed, remains the mainstay of therapy. CP may present as episodes of acute inflammation superimposed on a previously injured pancreas or as chronic fibrotic damage with persistent pain or malabsorption. Alcoholism is the most common cause of CP. The classic triad of pancreatic calcification, steatorrhea, and diabetes mellitus usually establishes the diagnosis of CP. ERCP and pancreatic function test are gold standard imaging procedures for diagnosing CP and planning treatment. Therapy for patients with CP is directed toward major problems such as pain, malabsorption, and diabetes mellitus. Pancreatic enzyme replacement therapy improves the abdominal pain and malabsorption. If Complications is found, endoscopic or Surgical treatments should be considered.

A Large Malignant Insulinoma: Case Report with Endosonographic, Immunohistochemical and Ultrastructural Features

Malignant insulinoma in the beta cells of the pancreatic islet is rare and usually presented as hypoglycemia. We report a case of large malignant insulinoma in a 53-year-old Korean woman. A presumptive clinical diagnosis was made before surgery, based on the high plasma insulin-to-glucose ratio and a large solitary heterogeneous pancreatic mass by abdominal computed tomography and endosonography. The tumor measured 5.8X4.7X4.5 cm in dimension and showed capsular invasions and metastases in two of four peripancreatic lymph nodes. The tumor cells were strongly immunoreactive to insulin and had a high Ki-67 labeling index (13%) and atypical membranous electron-dense granules, ranging from 120 to 400 nm in diameter, in the cytoplasm on electron microscopy. The patient was treated by distal pancreatectomy with splenectomy and rapidly recovered without neurohypoglycemic symptoms. This case showed not only lymph node metastases, the most reliable parameter for malignancy in pancreatic endocrine tumors, but also other valid diagnostic clues, such as high Ki-67 labeling index, heterogeneous enodosonographic findings, capsular invasions with large tumor and pure atypical secretory granules.

Correlation of liver-spleen scan findings with modified Child-Pugh classification / Correlation of liver-spleen scan findings with modified Child-Pugh classification

Background. The Child-Pugh classification is used as an index of liver function. We assessed the relationship between modified Child score and sulfur colloid liver-spleen scintigraphy in histologically confirmed cirrhosis. Method. Following injection of 185 MBq 99mTechnetium-sulfur colloid, anterior and posterior images were obtained at 30 minutes with 500,000 counts. Liver-spleen scintigraphy pattern was divided visually into three categories: A (liver uptake $ spleen uptake, without visualization of ribs and vertebrae), B (spleen uptake > liver uptake without visualization of ribs and vertebrae), and C (remarkable visualization of ribs and vertebrae). Results. Of 36 patients, 14 (38.8 %), 19 (58.8 %) and 3 (8.3 %) patients were categorized into Child-Pugh grades A, B and C, respectively, whereas 13 (36.1 %), 12 (33.3 %) and 11 (30.6 %) patients were categorized into scintigraphic grades A, B and C, respectively. In 14 patients the results of Child and scan classifications were in agreement, but in 22 patients the results were discordant. Kappa value was 0.072 (poor agreement). Conclusion. There is no correlation between scintigraphic and Child-Pugh classifications. Scintigraphic classification may present a marker of body reactions to the disease, independent of Child-Pugh modified classification. Further studies are needed to determine which one of these classifications has better concordance with the patient's outcome

Fundamentos. Se usa la clasificación de Child-Pugh como índice de la función hepática. Hemos evaluado la relación de la puntuación de Child modificada y la gammagrafía del hígado-bazo con sulfuro coloidal en cirrosis confirmada histológicamente. Método. Después de la inyección de 185 MBq de 99mTc-sulfuro coloidal, se adquirieron imágenes en proyecciones anterior y posterior a los 30 minutos de la inyección con 500.000 cuentas. El patrón de la gammagrafía del hígado-bazo fue dividido visualmente en tres categorías: A (captación del hígado $ captación del bazo, sin visualización de las costillas y vértebras), B (captación del bazo > captación del hígado sin visualización de las costillas y vértebras) y C (visualización destacada de las costillas y las vértebras). Resultados. De los 36 pacientes, 14 (38,8 %), 19 (58,8 %) y 3 (8,3 %) pacientes fueron agrupados en grados A, B y C de Child-Pugh, respectivamente, mientras 13 (36,1 %), 12 (33,3 %) y 11 (30,6 %) pacientes fueron agrupados en grados A, B y C de gammagrafía, respectivamente. En 14 pacientes los resultados de Child y las clasificaciones de la gammagrafía concordaban, pero en 22 pacientes los resultados fueron discordantes. El valor kappa fue 0,072 (concordancia pobre). Conclusión. No hay correlación entre gammagrafía y las clasificaciones de Child-Pugh. La clasificación de la gammagrafía puede ser un marcador de las reacciones corporales a la enfermedad, independiente de la clasificación modificada de Child-Pugh. Hacen falta más estudios para determinar cuáles de estas clasificaciones tienen mejor concordancia con el pronóstico del paciente

Avaliaçäo hematológica e bioquímica dos cäes da raça beagle / Hematological and biochemical evaluation of beagle dogs

O objetivo deste trabalho é determinar um padräo de valores bioquímicos que sirvam de referência para o hemograma e para as provas de funçäo hepática, renal e pancreática para cäes Beagle utilizados em pesquisa. As amostras de sangue foram coletadas de machos e fêneas, saudáveis, entre 1 e 2 anos de idade. foram realizados os exames: a)Hemograma - hematócrito, hemoglobina, leucócitos, segmentados, bastöes, linfócitos, monócitos, eosinófilos, plaquetas; b)Funçäo Hepática - TGO, TGP, fosfatase alcalina, LDH, colesterol total, bilirrubinas direta e total; c)Funçäo Renal - creatina, uréia; d)Funçäo Pancreática - amilase, lipase, proteína C reativa insulina, glicemia, hemoglobina glicosilada. Sugerimos que os valores do hemograma e das provas de funçäo hepática, renal e pancreática obtidas sejam utilizados como valores de referência para cäes da raça Beagle utilizados em pesquisa