H. Worning

Incidence of Alcoholic Chronic Pancreatitis in Copenhagen

A retrospective study of 126 patients with chronic pancreatitis diagnosed from 1970 to 1979 is presented. The aim was to evaluate whether the incidence of chronic pancreatitis had increased and to present briefly the clinical aspects of chronic pancreatitis in Copenhagen. The annual incidence of chronic pancreatitis rose from 6.9 to 10.0 per 100,000 during the 10 years of the study. This increase was only due to an augmentation in the number of patients with alcoholic chronic pancreatitis. Clinical aspects of chronic pancreatitis were similar to those found in other European countries. The present study suggests that alcoholic chronic pancreatitis will be a commoner disease in Denmark in the future.

Chronic pancreatitis in Copenhagen. A retrospective study of 64 consecutive patients.

A longitudinal study of 64 patients with chronic pancreatitis is presented. The patients were followed up for a median period of 4 years. Pain was the dominant symptom in 43 of the patients, but only 5 patients had pancreatic resection because of pain. Alcoholism was the etiology in 45 patients. Complications were common: 34 patients developed steatorrhea and 29 diabetes. Two major groups of associated diseases contributed to a high morbidity in chronic pancreatitis: 24 patients presented with duodenal ulcer, and 8 developed malignant tumors. This number is significantly higher than expected in a matched population (P less than 0.01). Twenty-six of the patients died within the observation period from complications of chronic pancreatitis (38%), from malignant neoplasms (15%), or from other causes (46%). The calculated mortality rate after 7 years of observation was close to 50%. Most patients were recruited from the lower social classes, and most were unemployed. We conclude that chronic pancreatitis in Copenhagen is associated with a high morbidity, a high mortality, and a poor social prognosis.

Metabolic control and B cell function in patients with insulin-dependent diabetes mellitus secondary to chronic pancreatitis

Among 88 unselected patients with chronic pancreatitis 35% (95% confidence limits 25 to 46) had insulin-dependent diabetes, 31% (21% to 41%) had non-insulin-dependent diabetes or impaired glucose tolerance (by intravenous glucose tolerance test), and 34% (24% to 45%) had normal glucose tolerance. B cell function measured by C-peptide concentration after 1 mg glucagon IV correlated with the pancreatic enzyme secretion (meal stimulated duodenal lipase content). B cell function was preserved to a greater extent (P less than .01), and glycosylated hemoglobin and fasting level of glucose were lower (P less than .01 to .05) in the 31 patients with pancreatogenic diabetes than than in 35 otherwise comparable patients with type I (insulin-dependent) diabetes, yet daily insulin dose was similar in the two groups. Glucagon stimulated C-peptide was inversely correlated to glycosylated hemoglobin in insulin-dependent patients with pancreatogenic diabetes and in type I diabetes. Since body mass indices were identical in the two groups, better glucoregulation was not due to reduced food intake or malabsorption in pancreatogenic diabetes. Rather residual B cell function and/or different secretion of other pancreatic hormones in pancreatogenic diabetes may account for different metabolic control in type I IDDM compared with insulin-dependent pancreatogenic diabetes.

B cell function in patients with chronic pancreatitis and its relation to exocrine pancreatic function

SummaryExocrine pancreatic function was evaluated by a Lundh meal test and a secretin-cholecystokinin test in 16 patients with chronic pancreatitis. B cell function was assessed by measuring the concentration of C-peptide after stimulation with oral glucose and intravenous glucagon. The C-peptide response to intravenous glucagon and oral glucose was closely correlated (r = 0.88,p < 0.01). Plasma C-peptide after glucagon was significantly correlated to the post-prandial concentration of lipase (r = 0.72,p < 0.001), amylase (r=0.64,p < 0.05) and to amylase output (r = 0.64,p < 0.05). Eight out of nine patients treated with insulin had residual B cell function, but it diminished significantly with increasing duration of diabetes. We conclude that B cell function is correlated to pancreatic enzyme secretion and that patients with insulin-treated diabetes secondary to chronic pancreatitis have a residual insulin secretion similar to that of patients with Type 1 (insulin-dependent) diabetes.

Glucose tolerance and B cell function in chronic alcoholism: Its relation to hepatic histology and exocrine pancreatic function☆

Glucose tolerance and B cell function were assessed in 30 consecutive chronic alcoholic patients without overt diabetes mellitus. Plasma glucose, insulin, and C peptide concentrations were measured during an oral glucose tolerance test. All patients underwent a liver biopsy and an exocrine pancreatic function test (Lundh test). Compared with the controls, the three groups of alcoholic patients (those with histologically normal livers, n = 12; those with steatosis, n = 10; and those with cirrhosis, n = 8) all had a two-fold increase in plasma concentrations of insulin as well as C peptide in the fasting state, despite normal fasting levels of glucose. After oral glucose all groups of patients had elevated plasma levels of glucose, insulin, and C peptide compared with the controls. The C peptide/insulin ratio was similar to that in the controls in all groups of alcoholics. Patients with decreased exocrine pancreatic function (n = 7) had a significantly lower insulin and C peptide response to glucose than the patients with normal exocrine pancreatic function. It is concluded that (1) chronic alcoholics even with histologically normal livers have endogenous insulin resistance, and (2) associated damage to the exocrine pancreas is more common than previously recognized and decompensation of B cell function could be demonstrated in patients with decreased exocrine pancreatic secretion.

Correlation between Exocrine Pancreatic Secretion and Serum Concentration of Human Pancreatic Polypeptide in Chronic Pancreatitis

Concentrations of human pancreatic polypeptide (HPP) in serum were measured in the fasting state and after a meal in 19 control subjects and 24 patients with chronic pancreatitis (CP). The severity of CP was characterized on the basis of the duodenal lipase concentration after a test meal (Lundh test). Basal and postprandial HPP concentrations were significantly (p less than 0.01) decreased in severe and moderate chronic pancreatitis and in diabetes secondary to pancreatitis. There was only a weak correlation (r = 0.44; p less than 0.05) between exocrine secretion and delta HPP in CP. Fifty-eight percent of patients with CP had serum concentrations of HPP within the normal range, limiting the value of serum HPP measurement in the diagnosis of CP.

The Effect of Enzyme Substitution in Patients with Pancreatic Insufficiency

Concentrations of pancreatic enzymes in the upper intestine during digestion of a meal were studied with and without different preparations of pancreatic extracts in 34 patients with severely decreased exocrine pancreatic function and in 17 patients with a partial gastrectomy (Billroth-II) and very low enzyme concentrations in the efferent loop. Granulated Pankreatin induced a dose-related increase in concentrations of amylase, lipase, and trypsin in the patients studied. The standard dose of 10 ml induced normalization of amylase and trypsin concentrations in a considerable number of patients, whereas the lipase concentration still was far below normal value. The increased concentrations of lipase resulted in a marked reduction of the fecal fat excretion. The induced increase in enzyme concentrations was for all enzymes significantly higher in the partially gastrectomized patients. Eight other pancreatic supplementary preparations were tested; only one of these was able to induce significant increases in enzyme concentrations.

Short report: lipid and vitamin B12 malassimilation in pancreatic insufficiency

Patients with exocrine pancreatic insufficiency have steatorrhoea as well as vitamin B12 malassimilation. To investigate whether this is caused by the pancreatic insufficiency per se or whether intestinal bacterial overgrowth contributes to the condition, 10 patients with pancreatic steatorrhoea were studied. Intestinal culture was done. Lipid and vitamin B12 assimilation was estimated from faecal spot tests, using 14C‐triolein and 58Co‐vitamin B12 as tracers and 51CrCl3 as marker. Out of the 10 patients, 9 had either vitamin B12 malassimilation (n= 8), and/or bacterial overgrowth (n= 5). These 9 patients were retested with pancreatic enzyme therapy, with and without addition of the antibiotics metronidazole and cefalexin. The lipid assimilation was significantly increased by enzyme therapy but did not improve further on additional antibiotic treatment. The vitamin B12 assimilation did not improve significantly on enzyme therapy nor with additional antibiotic treatment.

Monitoring the Effect of Substitution Therapy in Patients with Exocrine Pancreatic Insufficiency

Twenty-three outpatients with chronic pancreatitis and severe exocrine insufficiency were studied for the purpose of comparing the effect of Pancrease, Pankreon, and Pankreatin by estimation of duodenal enzyme activity, the faecal fat excretion, and the faecal 14C-triolein-3H-oleic acid test and, at the same time, to evaluate these tests when monitoring outpatients. The three preparations did not disclose any significant difference in treating steatorrhoea. Pankreatin increased the meal-stimulated duodenal enzyme activity (p less than 0.01) and caused reduction in the faecal fat excretion (p less than 0.05), whereas no change in these variables were observed with Pankreon or Pancrease. The faecal 14C-triolein-3H-oleic acid test showed significant improvement in the 14C-triolein digestion with all three preparations (p less than 0.01). The faecal 14C-triolein-3H-oleic acid test was the most reliable when monitoring outpatients.

The Pancreatic Secretion of Amylase as Compared to the Amylase Concentration in the Intestinal Contents after Ingestion of a Meal

In 54 subjects (17 controls, 27 patients with pancreatic diseases, and 10 patients with intestinal malabsorption syndromes), the pancreatic secretion of amylase during constant intravenous infusion of secretin and pancreozymin was compared to the mean concentration of amylase in the duodenal contents in an 80-minute period following ingestion of a fluid standard meal. A reliable linear correlation between the two parameters was observed. The regression lines were nearly identical in the three groups of subjects studied. A common regression line was calculated. The result implies that the concentration of pancreatic enzymes in the small intestine during digestion of a meal is primarily estimated by the enzyme-secreting capacity of the pancreas, and that the meal test for pancreatic function is very usable in order to characterize the secretory function of the pancreas.