Girdwood Ah

Relapse rates after initial ulcer healing with sucralfate and cimetidine.

The relapse rate after successful short-term therapy with sucralfate (Sc) or cimetidine (Cm) was studied in a group of 86 patients with recently healed duodenal or gastric ulcers. The patients were endoscoped on clinical relapse or, routinely, at 6 weeks, 6 months, and 1 year. Patients whose ulcers had healed with Cm relapsed earlier than did those whose ulcers had healed with Sc (p less than 0.05 at 12 weeks), but the cumulative relapse rate by the end of 1 year was of the order of 70% in both treatment groups. The mean duration of remission in patients who developed a recurrence was significantly greater in patients treated initially with Sc than in those treated initially with Cm--7.3 and 4.6 months, respectively (p less than 0.01).

The spectrum and natural history of common bile duct stenosis in chronic alcohol-induced pancreatitis

Sixty patients with chronic alcohol-induced pancreatitis with endoscopic retrograde cholangiopancreatography evidence of common bile duct stenosis were studied to determine the clinical spectrum and natural history of this complication, as well as the indications for biliary bypass. In 17% of patients, common bile duct stenosis (CBDS) was an incidental finding at ERCP, while in the remaining cases pain and jaundice were the predominant symptoms in 35% and 48%, respectively. Biliary drainage was performed in 38% of patients for persistent or recurrent jaundice, cholangitis, and while undergoing pancreatic duct or cyst drainage procedures for pain. The benign nature of CBDS in chronic alcohol-induced pancreatitis (CAIP) in patients without persistent jaundice is emphasized. In particular, no histologically proved cases of secondary biliary cirrhosis were noted. The majority of patients with CBDS due to CAIP may be safely managed without biliary bypass but require close follow-up.

Pancreatic enzyme replacement therapy

The relative efficacy of three commercial pancreatic enzyme supplements in improving fat absorption was studied using the [14C]triolein breath test in 12 patients with chronic pancreatitis. Two of the supplements were enteric coated. The one nonenteric coated product was studied twice: with and without ranitidine coadministration. Doses complied with the manufacturers recommendations. Baseline studies included pentagastrinstimulated gastric acids, 72-hr fecal fat excretion, and [14C]triolein absorption while not on supplementation. Acid outputs were variable (BAO: 0.3–4.1 meq/hr; MAO: 3.5–34.6 meq/hr). Three patients had mild steatorrhea (i.e., <10 g/day) and the remaining severe fat malabsorption (56.9±41.5 g/day). Although fat absorption was significantly improved by all three supplements, the nonenteric coated preparation was most effective (P< 0.001). However, laboratory analysis demonstrated that lipase content was four times greater, ie, 17,000 IU/4 tablets. Pretreatment with ranitidine failed to further improve the absorption in patients given nonenteric supplements but was effective in those found to have high or normal acid outputs (P<0.001). Our results suggest that the recommended dosage of enteric coated preparations is insufficient for adult patients with severe chronic pancreatitis. Secondly, the marked variability of acid secretion in such patients possibly accounts for the variability of results obtained by others on the usefulness of coadministration of antacids and H2 antagonists. Routine measurement of gastric acid secretion status may help optimize the choice and form of pancreatic enzyme supplementation.

Maintenance therapy with sucralfate reduces rate of gastric ulcer recurrence

Seventy-two patients with recently healed gastric ulcers were entered into a double-blind, placebo-controlled, six-month maintenance trial to assess whether sucralfate, 1 g in the morning and 2 g at night, reduces the propensity for recurrent ulceration. Patients were assessed clinically at 0, 6, 12, 18, and 24 weeks. Endoscopy was performed at the time of entry into the study and at 24 weeks, or earlier if clinical relapse occurred during this period. Eleven patients were excluded from the study because they defaulted or for other protocol violations. The other 61 patients were followed for six months or until evidence of ulcer relapse. Endoscopic recurrence was found in five of 31 patients (16 percent) randomly assigned to receive sucralfate and in 21 of 30 patients (70 percent) assigned to receive placebo. Most recurrences occurred during the first 12 weeks, with relapse rates of 10 percent and 53 percent, respectively for the sucralfate- and the placebo-treated groups. Three of the recurrences noted at 24 weeks were asymptomatic; two of these were in the sucralfate-treated group. The results indicate that a 3 g per day maintenance dose of sucralfate offers meaningful protection against recurrent gastric ulceration.

Nocturnal dosage regimen of sucralfate in maintenance treatment of gastric ulcer.

Sixty-six patients with recently healed gastric ulcers were entered into a double-blind, placebo-controlled, six-month maintenance trial to determine whether sucralfate 2 g at night reduces the liability to recurrent ulceration. Thirty-three patients were randomly assigned to treatment with sucralfate and 33 were assigned to placebo. Endoscopy was performed at the time of entry into the study and at 24 weeks, or earlier if clinical relapse occurred during this period. Of the patients available for analysis, endoscopic recurrences were found in eight of the 29 patients (28 percent) randomly assigned to sucralfate and in 15 of the 27 patients (56 percent) assigned to placebo. Eight of the recurrences noted at 24 weeks were asymptomatic and, of these, five were in the placebo-treated group. The cumulative relapse rate at 24 weeks was significantly lower in the sucralfate-treated group (p less than 0.05), and the Cox-Mantel text showed a significant difference between the cumulative relapse curves of the two treatment groups over the 24-week period (p less than 0.05). The results indicate that a single maintenance dose of sucralfate 2 g at night reduces the relapse rate in patients with recently healed gastric ulceration.

Comparison of the oral (PABA) pancreatic function test, the secretin-pancreozymin test and endoscopic retrograde pancreatography in chronic alcohol induced pancreatitis.

The oral (PABA) pancreatic function test (PFT), the secretin-pancreozymin test and endoscopic retrograde pancreatography (ERCP) have been carried out in 32 patients with suspected chronic alcohol induced pancreatitis (CAIP) in order to evaluate which, if any, test was most likely to confirm the provisional diagnosis. Thirty one patients had changes of minimal (n = 6) moderate (n = 7) or advanced (n = 18) chronic pancreatitis on pancreatography, whilst one patient had a pancreas divisum. Eight hour urinary PABA excretion was significantly reduced in patients with moderate and advanced structural changes (p less than 0.001) and correlated significantly with all parameters of the PFT, although eight patients with an abnormal pancreatogram and pancreatic function test had a normal PABA value. The PFT was abnormal in 23 patients, but normal in five patients with an abnormal pancreatogram and low PABA value. Most patients with minimal change pancreatitis had a normal PABA test and PFT. We conclude that pancreatography appears to be the most sensitive method for detecting chronic pancreatic damage and for confirming a clinical diagnosis of chronic alcohol induced pancreatitis. Both the PFT and PABA test are useful confirmatory tests and whilst the PFT is slightly more sensitive for assessing pancreatic exocrine function, the PABA test is well tolerated and simple to perform. It may therefore be the complementary investigation of choice for this group of patients.

A maintenance regimen of sucralfate 2 g at night for reduced relapse rate in duodenal ulcer disease: A one-year follow-up study

One hundred seventeen patients with recently healed duodenal ulcers were entered into a one-year maintenance study. Patients were randomly assigned to treatment with sucralfate 2 g at night, cimetidine 400 mg, or placebo. The sucralfate versus placebo leg of the study was double-blind, whereas the cimetidine leg was single-blind. Endoscopy was repeated on clinical relapse and routinely at six and 12 months. Ninety-six of the 117 patients were followed up for one year or to an endoscopically proven recurrence. The remaining 21 patients were excluded from analysis because of default or protocol violation. The one-year analysis showed by endoscopy that ulcers had recurred in 17 of the 31 sucralfate-treated patients, 19 of the 32 cimetidine-treated patients, and in 28 of the 33 placebo-treated patients. These data included asymptomatic recurrences in four, four, and three patients, respectively. The relapse rate at 24 weeks was greater in patients healed initially with a histamine (H2)-blocker alone than in those healed initially with sucralfate alone, a combination of sucralfate with a H2-blocker or an antacid alone.

Periampullary cyst: a surgically remediable cause of pancreatitis.

We report two patients with periampullary cysts associated with recurrent attacks of acute pancreatitis. In both patients the diagnosis was made preoperatively by upper gastrointestinal endoscopy and ERCP, which was also useful in determining the relationship of the cysts to the biliary and pancreatic ductal systems. Simple marsupialisation of the cysts resulted in long term relief of symptoms. Congenital cystic anomalies in the second part of the duodenum should be diligently sought in patients with pancreatitis of unexplained cause, as surgical therapy is safe and effective.

Enteric-coated pancreatic enzyme supplementation. A dose-response study

Abstract Nine patients with pancreatic steatorrhoea were investigated to assess the effect of increasing dosages of the enteric-coated preparation, Pancrease, on fat absorption. Baseline studies of gastric acid output, 72-h faecal fat excretion and 14 C triolein breath test were performed. The latter was repeated on alternative days using 2, 4 and 8 capsules of an enteric-coated enzyme preparation (Pancrease). Twenty healthy subjects served as controls for the 14 C triolein breath test. Stool fat excretion showed that all but one of the patients had severe steatorrhoea (mean 191 ± 15 mmol/day). The mean baseline 14 C triolein breath test was 1.14 ± 0.95%/h and significantly lower ( P r = 0.67, P 14 C triolein breath test after 2, 4 and 8 capsules of Pancrease was 226 ± 221%, 317 ± 237% and 336 ± 223%, respectively. Fat absorption was significantly improved by all three regimens. The 4- and 8-capsule schedule was significantly better than the 2-capsule one, but the 8-capsule dose was not better than the 4. The improvement in fat absorption in more than half the patients was insufficient to achieve a normal breath test. The efficacy of the response to increasing dosages of Pancrease did not correlate with gastric acid output. Our results suggest that 4 capsules are as effective as 8 in improving the absorption of 25 g fat, which is the usual fat content of a normal diet.