Carlo Sembenini

Medium-Chain Triglyceride Absorption in Patients with Pancreatic Insufficiency

BACKGROUND The role of medium-chain triglycerides (MCTs) in the management of patients with pancreatic insufficiency is controversial. The aim of the study was to evaluate the absorption of MCTs in the presence of pancreatic insufficiency and the effect of pancreatic extracts on MCT absorption so as to clarify whether the replacement of usual dietary fats with MCTs is cost-effective. METHODS Six patients with severe pancreatic steatorrhea were for 5 days fed a low-fat diet to which butter (long-chain triglycerides (LCTs)) or MCT oil was added, with and without pancreatic extracts, in a crossover design. RESULTS Fecal weight and nitrogen losses were the same during MCT and LCT intake. Steatorrhea was substantial during both periods but was significantly lower during MCT than LCT intake. Fecal weight and nitrogen and fat losses were reduced by pancreatic extracts in both diets. Steatorrhea was the same when MCTs and LCTs were consumed together with pancreatic extracts. CONCLUSIONS MCTs are absorbed better than LCTs in the presence of pancreatic insufficiency but require pancreatic extracts for optimal absorption. No advantage is to be expected from replacing usual dietary fats with MCTs if pancreatic supplements are used.

Omeprazole causes delay in gastric emptying of digestible meals

We have studied gastric emptying of a solid, realistic meal (800 cal, 15% protein, 45% fat, 40% carbohydrate) in 21 healthy subjects twice, with and without a four-day pretreatment with 40 mg omeprazole. The last dose of the drug was taken 24 hr before the test, to avoid hypothetical nonsecretory side effects of the drug. Gastric emptying was measured by ultrasound of antral diameters. The results show that basal and maximal postprandial antral cross-sectional areas were the same during the two tests. A greater residual distension of the antrum was present throughout the study after the omeprazole treatment, the difference being significant at time 120 and 240. Omeprazole induced a highly significant delay in gastric emptying [control 199.6 (12.6) vs omeprazole 230.9 (12.7) min, mean (1sem);P<0.003]. The delay was not due to a prolonged lag phase, but rather to an effect on the slope of the emptying curve. This study shows that in normal subjects omeprazole delays gastric emptying of a digestible solid meal.

Pathological esophageal acidification and pneumatic dilatation in achalasic patients too much or not enough

Endoscopy, esophageal manometry and pH monitoring, gastric emptying test, and heartburn quantification on a visual analog scale were performed in 22 achalasic patients in order to clarify which events are associated with pathological esophageal acidification after successful LES dilatation. Five patients presented pathological acidification. Dilatation reduced LES tone from 38.3 ± 4.2 to 14.6 ± 1.1 mm Hg (mean ±sem); there was, however, no difference between nonrefluxers and refluxers (14.8 ± 1.2 vs 13.8 ± 2.5 mm Hg). The emptying time in achalasic patients was delayed compared to controls (315.9 ± 20.9 min vs 209 ± 10.4) due to prolonged lag-phase and reduced slope of the antral section-time curve, but, again, there was no difference between refluxers and nonrefluxers. The acid clearance was delayed in refluxers compared to nonrefluxers (15.9 ± 4.5 vs 2.5 ± 1.8 min,P<0.05). Two refluxers presented grade 1 esophagitis; one of them developed an esophageal ulcer. The heartburn score was the same in refluxers and nonrefluxers. Pathological acidification after pneumatic dilatation is associated with persistent problems in esophageal emptying rather than with excessive sphincter divulsion.

Gastric emptying of solids is markedly delayed when meals are fried.

We studied the effect of heat-treated fats on gastric emptying. Eight healthy asymptomatic volunteers (five males; age 28–41 years) ate on different days and in random order two meals identical in contents (pasta, tomato, beef, olive oil, carrots, orange, water; 870 kcal males, 700 kcal females; 47% of calories from carbohydrate, 36% from fat, 17% from protein), but cooked differently (fats fried or not). Ultrasound measurement of antral diameters was used to calculate basal antral section, its maximal dilation after the meal, the time necessary for total emptying, and the percent retention at hourly intervals. No difference was found in basal and maximal antral diameters after the two meals. On the contrary, total gastric emptying was significantly delayed after the fried meal [317.1 (24.12) vs 226.7 (18.4) min, mean (1sem);P≪0.002]. A significantly greater percentage of maximal antral distension was still present between 120 and 240 min after the fried meal. The glycemic response and hunger feeling were the same after the two meals, whereas there was a longer persistence of satiety and epigastric fullness after the fried meal. In conclusion, gastric emptying can be influenced not only by the meal content, but also by the way it is cooked.

Gastric Emptying of Realistic Meals With and Without Gluten in Patients with Coeliac Disease. Effect of Jejunal Mucosal Recovery

BACKGROUND Few data are available on disturbed gastric emptying in patients with coeliac disease. The aims of the study were to investigate (a) the presence of delayed gastric emptying: (b) the acute effect on gastric emptying of gliadin; and (c) the effect of jejunal recovery on gastric emptying of meals with or without gluten in such patients. METHODS We measured gastric emptying of two meals in 16 patients with coeliac disease; one meal contained gliadin. Results were compared with those obtained in 24 controls. In 12 patients, both measurements were repeated after mucosal recovery. Statistical analysis was performed using the analysis of variance for repeated measurements and Students t test. Mean +/- 1 s(mean) (standard error of the mean) are shown. RESULTS No difference was found in fasting and in maximal antral sections after the two meals. On entry, gastric emptying was significantly (P < 0.001) delayed compared to controls both after the meal containing gluten (326.9 +/- 12.4 min versus controls 213.5 +/- 11.5) and after the gluten-free meal (315.3 +/- 16.7 min). After jejunal recovery, emptying of the meal containing gluten remained unchanged (337 +/- 18.9 min), whereas emptying of the gluten-free meal was significantly shortened (280.6 +/- 10.5 min; P < 0.001). CONCLUSIONS In coeliac disease there is an impairment of gastric emptying which is at least partially reversible. This suggests either an immunological disorder or that unabsorbed meal constituents are responsible for an ileal-brake effect.Background: Few data are available on disturbed gastric emptying in patients with coeliac disease. The aims of the study were to investigate (a) the presence of delayed gastric emptying; (b) the acute effect on gastric emptying of gliadin; and (c) the effect of jejunal recovery on gastric emptying of meals with or without gluten in such patients. Methods: We measured gastric emptying of two meals in 16 patients with coeliac disease; one meal contained gliadin. Results were compared with those obtained in 24 controls. In 12 patients, both measurements were repeated after mucosal recovery. Statistical analysis was performed using the analysis of variance for repeated measurements and Students t

Gastric emptying of solid meals in achalasic patients after successful pneumatic dilatation of the cardia

Gastric emptying of a solid meal was measured by ultrasound scanning in 16 achalasic patients following successful pneumatic dilatation of the lower esophageal sphincter. The data were compared with those of a control group of 15 healthy subjects. Fasting and maximal postcibal antral sections were very similar in the two groups. On the contrary, the time interval before maximal antral dilatation, and the time necessary for the emptying of half or of the whole meal were significantly longer in the achalasic patients than in the controls. Half of the achalasic patients had longer emptying times than the upper normal limit. The percentage of the meal retained in the antrum at each hourly interval was significantly higher in the achalasic group. The finding of a high prevalence of gastric emptying disturbances suggests that the functional derangement in achalasia is not limited to the esophagus.

Fecal Fat Concentration in the Screening of Steatorrhea

We studied if the fecal fat concentration as measured by the near infrared reflectance analysis in a spot sample is an acceptable screening test for malabsorption. This measurement was compared with the more complex fat balance in 120 patients with a suspected malabsorption [53 with chronic pancreatic disorders (CP), 67 with other digestive disorders (nCP)]. The fecal fat concentration proved to be well correlated with steatorrhea in CP (r = 0.86) but not in nCP (r = 0.35). A fat concentration of 9 g% had a sensitivity and a specificity for steatorrhea of 88.8% and of 97.1% in CP, but only of 53.8% and of 94.4% respectively in nCP. The fecal fat concentration was significantly higher in CP than in nCP, even considering patients with steatorrhea only; however, the overlap between the two groups was too high to suggest a clinical usefulness of this test in the differential diagnosis of steatorrheas. It is concluded that the fat concentration in a small sample, easily obtained also in outpatients, is useful in the selection of patients with chronic pancreatitis to submit to a proper fat balance study.

Elastase-1 vs trypsin, lipase and amylase serum levels in pancreatic diseases.

SummarySerum levels of elastase-1 were measured in 174 patients with pancreatic diseases and in 131 controls and were compared with the circulating levels of trypsin, lipase and amylase and with clinical data. In 48 patients with chronic pancreatitis serum enzyme levels were also compared with the pancreatic exocrine capacity. About 50% of the patients with chronic pancreatic disease showed increased levels of serum elastase, sometimes even in the face of long lasting pain-free periods, and/or of severe pancreatic impairment. On the contrary, serum trypsin and lipase were almost always either normal or below the normal range in the absence of painful relapses and/or in the presence of an impairment of the exocrine pancreatic function. A strict correlation was found between elastase-1 and trypsin (r=0.778) and lipase (r=0.834). However, controls and patients with chronic pancreatic diseases behaved differently, an increase in trypsin and in lipase levels being associated in the patients with chronic pancreatitis with an increase in elastase-1 values significantly larger than that observed in controls. These findings raise the hypothesis, at present unproven, that trypsin and lipase serum assays are more reliable indices of pancreatic exocrine function, whereas serum elastase-1 levels may indicate the presence of acute pancreatic episodes, even if subclinical, the importance of which, in the natural history of the disease, remains unknown. *** DIRECT SUPPORT *** A00DX035 00007

Achalasia : A possible late cause of postpolio dysphagia

The aim of this paper is to describe a patient with severe postpolio problems who developed achalasia. A 66-year-old patient came to our observation for severe dysphagia. He had suffered from paralytic poliomyelitis at the age of 7 months and had severe residual deficits. At the age of 62 he presented with sudden pain localized in the distribution of the C4 and C5 dermatomes and an inability to abduct the left arm. At the time, he experienced only occasional and mild dysphagia; his esophagus was not dilated and emptied normally. Over the following months his muscular function improved, but dysphagia worsened. We found a megaesophagus with a sigmoid appearance and the manometric features of achalasia. Pneumatic dilatation produced good resolution of dysphagia. A year later manometry showed the reappearance of peristalsis after all wet swallows. In patients with postpolio dysphagia, the possible presence of achalasia must be considered.

Fecal fat measurement in the presence of long- and medium-chain triglycerides and fatty acids. Comparison of three methods.

BACKGROUND It has been suggested that some of the limitations of the Van de Kamer method for fecal fat measurement could be overcome with the Jeejeebhoy method or the near-infrared reflectance assay. METHODS To test this hypothesis, a fecal fat test was carried out with the three methods, adding butter or MCT oil to the diet of four steatorrhoic patients. An in vitro recovery study of long- and medium-chain triglycerides was also performed. RESULTS The Jeejeebhoy method measured long- and medium-chain fats more accurately than the Van de Kamer method. It found consistently higher steatorrhea values. Mean results of the near-infrared reflectance analysis resembled those of the Van de Kamer method, but with wide discordance of individual data. CONCLUSION The Jeejeebhoy method is more accurate than the Van de Kamer method for fecal fat measurement. The difference may be clinically relevant when most fecal fatty acids derive from medium-chain triglycerides. Near-infrared reflectance may be a viable proposition only when a greater degree of approximation is acceptable.