patients with chronic pancreatitis

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1 Gut, 979,, Pure pnreti juie studies in norml subjets nd ptients with hroni pnretitis M.. DNYR ND P. B. COTTON From the Gstrointestinl Unit, The Middlesex Hospitl, London SUMMRY Pure pnreti juie ws obtined from within the pnreti dut in 54 ptients fter endosopi nnultion of the ppill of Vter. In ll norml subjets there ws brisk response to intrvenous injetions of GIH seretin in smll dosge ( nd 4 CU). Pek birbonte onentrtions ourred fter 4 CU stimulus, wheres volumes, nd birbonte nd protein outputs were gretest fter 7 CU. Totl protein nd mylse onentrtions were highest in the first speimens olleted from eh ptient, nd fell rpidly fter stimultion. Plteu levels for ll indies were hieved - minutes fter strting infusions of seretin nd pnreozymin. When norml ptients nd those with hroni pnretitis were ompred, there ws onsiderble overlp in ll indies (volume, birbonte nd totl protein onentrtions) fter bolus injetions of seretin. Most ptients with hroni pnretitis hieved pek birbonte onentrtion in exess of mmol/l. The medin onentrtions were not signifintly different from norml fter ny dose of seretin when pooled minute smples were nlysed. However there were signifint differenes in pek birbonte onentrtions (fter nd 4 CU, but not fter 7 CU), when one minute smples were ompred. There were lso sttistilly signifint differenes in the medin minute responses for volume fter nd 7 CU, for birbonte output fter, 4, nd 7 CU, nd for protein output fter 7 CU. The results ofjuie studies in ptients believed to hve erly hroni pnretitis did not differ signifintly from those in norml subjets or those with hroni pnretitis. ndosopi dut nnultion nnot gurntee omplete reovery of pnreti seretions, nd mesurements of volume nd output my be inurte. When stndrd biohemil indies re used, the dignosti role of pure juie studies is limited; further reserh my revel more speifi disese mrkers. Muh of our knowledge of humn pnreti exorine funtion hs been derived from stndrd pnreti funtion tests, whih involve the olletion of duodenl ontents fter hormone stimultion. However, reovery in suh studies in unpreditble, nd pnreti juie is neessrily ontminted by bile nd other seretions. The fibreopti duodenosope now llows deep nnultion of the ppill of Vter in onsious subjets. The tehnique hs minly been used for dignosti retrogrde holngiogrphy nd pnretogrphy (Cotton, 977) but lso permits the olletion of unontminted pnreti juie (nd bile) (Cotton et l., 974). We hve explored the pure pnreti juie response to grded doses of seretin nd pnreozymin in norml subjets nd ptients with pnretitis. Reeived for publition September Methods PTINTS Pure pnreti juie (PPJ) olletions were ttempted in 68 ptients who hd been referred for investigtion of known or suspeted pnreti disese. ll ptients hd lredy undergone dignosti endosopi retrogrde holngiopnretogrphy (RCP). Fifty-four olletions were suessful in 5 ptients, but five ptients were exluded from nlysis beuse the finl dignosis ws not ler t the end of the study. The remining 47 ptients hve been divided into three groups: norml, hroni pnretitis, nd probble erly hroni pnretitis. The riteri used in lssifition re shown in Tble. mong the 9 ptients finlly judged to hve no pnreti disese, four hd pepti ulers nd two were shown to hve gllstones. No Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

2 9 M.. Denyer nd P. B. Cotton Tble Dignosti riteri used in lssifying ptients Group Number of ptients Investigtions performed RCP Stndrd PFT Ultrsound Lprotomy N quiv bn Norml pnres N N N 3 3 N N N N N Totl ?Chroni pnretitis quiv quiv N Totl Chroni pnretitis 3 bn bn 4 CP bn bn bn CP bn bn CP Totl Grnd totls N: norml, quiv: equivlent, bn: bnorml, CP: hroni pnretitis; PFT: seretin-pnreozymin funtion test. orgni use for the presenting symptoms ws found in the reminder, nd no evidene of pnreti disese hs beome evident in follow-up period of one to three yers. The 4 ptients lssified s suffering from hroni pnretitis ll hd evidene of irreversible pnreti dmge (Tble ). Only two ptients showed lifition on plin rdiogrphs, nd none suffered from dibetes mellitus. The third nd intermedite group of ptients lssified s? erly hroni pnretitis onsisted of 4 ptients who hd suffered reurrent ttks of pnreti type pin for t lest two yers, but in whom stndrd investigtions (Tble ) showed no ler-ut evidene of hroni pnretiti dmge. ight of these ptients hd suffered well-doumented ttks of ute pnretitis (with serum mylse levels greter thn three times the norml) on one or more osions before the study (but not within two months of investigtion). PPJ olletions were performed in stndrd mnner, with the ptient lying in the left lterl semiprone position. ll ptients were strved overnight nd sedted with intrvenous injetions of dizepm (Vlium) in dose of 5- mg. No ntiholinergi gents were used. Cnnultion ws performed with stndrd side-viewing duodenosope nd Teflon theter ('6 mm externl nd mm internl dimeter) with single end-hole. The theter ws primed with dilute indoynine green to mrk its ded spe. Deep nnultion ws judged to hve been hieved when the theter tip hd pssed more thn m through the ppill. PPJ ws olleted by syphonge t 75 m below the mouth, in one minute smples for up to one hour. Purified porine seretin nd holeystokininpnreozymin were obtined from the Gstrointestinl Hormone Lbortory, Krolinsk Institute, Stokholm. Hormones were dissolved in stndrd mixture of 6'5 ml '9 % sline, ml Trsylol for stbilistion nd.5 ml humn serum lbumin to prevent ggregtion of moleules when using very smll doses. Suffiient diluent ws dded to eh mpoule of seretin or holeystokinin-pnreozymin to provide onentrtion of CU/ml. Individul doses were then withdrwn. ml insulin syringe ws used for smll doses, whih were further diluted to 5 ml with the diluent. ll doses were prepred immeditely before injetion. Injetions were given fter five minute bsl olletion period. The first 34 ptients reeived bolus intrvenous injetions of seretin of inresing strength t minute intervls (, 4 nd 7 CU, pproximting to '4,.57 nd - CU/kg). Nine ptients lso reeived n initil dose of '5 Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

3 Pure pnreti juie studies in norml subjets nd ptients with hroni pnretitis CU (pproximtely 7 CU/kg) nd five ptients were given n dditionl injetion of the diluent solution lone during the sequene. In the remining 5 studies, n initil bolus intrvenous injetion of 4 CU GIH seretin ws followed fter minutes by n infusion of seretin plus holeystokininpnreozymin (both CU/kg/hour) for up to 4 minutes. PPJ smples were olleted over ie, frozen, nd mintined t - C before nlysis. Volumes were mesured by weighing; onentrtions of sodium nd potssium by flme photometry; hloride with orning el hloride meter; birbonte by the method of Vn Slyke using Ntelson mirogsometer; totl protein by modified Lowry method (Huemer nd Lee, 97) nd mylse tivity by n iodometri method (Pimstone, 965). Between bth oeffiients of vrition rnged from 5 % for sodium to 6.3 % for totl protein, nd the within bth oeffiient of vrition for mylse estimtions ws %. In omprisons between groups of ptients, the results were expressed for eh minute period in terms of volume, men birbonte onentrtion, birbonte output, men protein onentrtions, mylse, nd protein output. Sine dt were not normlly distributed, sttistil nlyses were performed using the Wiloxon Rnk test. Results NORML SUBJCTS Bolus injetions brisk flow of juie followed within minutes of the 4 3 z ". o._ m 9 Volume (mllmi n) Seret in Cu.5 4 intrvenous injetion of seretin in ll ptients, even t the lowest doses (Figs nd 7). The response inresed in size nd durtion with inresing doses. Within individuls, the sodium nd potssium onentrtions remined lmost onstnt throughout the studies, wheres the birbonte nd hloride onentrtions losely pproximted to the sum of the sodium nd potssium onentrtions (Fig. ). Birbonte onentrtion rose less rpidly thn the volume fter the initil stimulus, but this prtly reflets the dedspe of the theter. In most norml subjets the pek onentrtion ws hieved fter 4 CU, nd ws lower fter 7 CU (Figs 3 nd 8). The birbonte output, however, rose progressively with inresing stimultion (Figs 4 nd ). In norml subjets the highest totl protein onentrtions were seen in the first speimens olleted (Fig. 5), with rpid fll to plteu s stimultion ontinued. h seretin injetion, however, resulted in trnsient but mrked rise in protein onentrtion (Fig. 5). mylse nd protein onentrtions were signifintly orrelted (rs =.88, n = 98, p < ). Ten minute protein outputs rose progressively fter eh stimulus. 4 7 Infusions Volume response to seretin-holeystokinin-pnreozymin infusion rehed plteu (of pproximtely 4 ml/min) fter -3 minutes, but there ws tendeny for birbonte onentrtions to fll lter (Fig. 6). The totl protein onentrtion fell to onstnt level over the sme period. The plteu vlue for eh index ws similr to tht Fig. Volume nd birbonte onentrtions in PPJ fter grded bolus intrvenous injetions of seretin in one norml subjet. 9 Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

4 9 6j g %,,ss~~~~ '-- f j. DC n- j ;-6><>,O Seretin Cu 'O. H-C HCO- oo' Cl PI ~--- l- M inutes Fig. letrolyte hnges in one norml subjet fter inresing doses of seretin. The sums of the tions, (solid line) nd nions (dshed line) re similr, t the top of the grph. C seen fter the 7 CU bolus injetions in other norml subjets (Fig. 7). PTINTS WITH CHRONIC PNCRTITIS ND? RLY CHRONIC PNCRTITIS Bolus injetions There ws onsiderble overlp in the response of these two groups of ptients when ompred with the norml subjets, in terms of volume (Fig. 7), minute birbonte onentrtion (Fig. 8), nd birbonte output (Fig. ). Sttistilly signifint differenes were found between norml subjets nd those with estblished hroni pnretitis for volume fter nd 7 CU, for minute birbonte onentrtion only fter 4 CU, nd for birbonte output fter ll stimuli (Tble ). When one minute peks of birbonte onentrtion were ompred, however, signifint differenes were found between norml subjets nd ptients with hroni pnretitis fter nd 4 CU doses of seretin (Fig. 9). In ptients with hroni pnretitis the protein onentrtion in the first juie olleted (fter I CU) 4 V _= 3 U to f.d. CO LIn F F _ M.. Denyer nd P. B. Cotton 4 7 CCu.7.4 Seretin.57 Ctu/kg Fig. 3 Birbonte onentrtions in ll norml subjets fter grded bolus intrvenous injetions of seretin. The medin vlues re shown by dotted lines. The medin vlues between nd 4 CU, nd between 4 nd 7 CU re signifintly different (p <.5). ppered higher thn in norml subjets, but the differenes did not reh sttistil signifine (Tble ); the protein output ws signifintly less fter 7 CU mong ptients with hroni pnretitis. No signifint differene for ny index ws seen between norml subjets nd those with probble erly hroni pnretitis, nor between the ltter nd those with estblished hroni pnretitis. Infusions The numbers in the three groups of ptients were smll, therefore no sttistil omprison ould be mde. There ws tendny for volume, birbonte output, nd protein output to be higher in norml subjets thn in those with hroni pnretitis (Tble 3) but no other obvious differene ws observed. Disussion Humn pure pnreti juie studies re tehnilly demnding, nd few results hve been published. Our studies provide some bse line informtion bout the response of the norml pnres to seretin, nd the results with very smll doses (.5 nd CU) re prtiulrly interesting. When Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

5 Pure pnreti juie stuidies in norml subjets nd ptients with hroni pnretitis. n 6 5 7~~~~~~~~~~~~~~~~~~ ~~4 6 7OCu l Culkg Seret in Fig. 4 Birbonte outputs in ll norml subjets fter grded bolus intrvenous injetions of seretin Cn _- 4 G NMinutes Seretin 4 6 diluent 7 given by slow intrvenous infusion, these doses use rises in serum levels in immunoretive seretin, omprble with those hieved by endogenous relese fter intrduodenl infusion of id (Wrd nd Bloom, 974); this suggests tht they re within the physiologil rnge. Similr pure juie responses were reported by Domshke et l. (976) using low dose seretin infusion. The volume response to 7 CU (roughly CU/kg) in our norml subjets ws similr to tht reported by Gregg nd Shrm (975) using Boots seretin but greter thn tht reorded by Kwnishi et l. (975). The finding of higher birbonte onentrtion fter 4 CU thn fter 7 CU ords with the findings of Domshke et l. (976), nd erly work on duodenl juie (Wormsley, 968). To liniins, lk of onvining differenes between norml subjets nd ptients with hroni pnretitis will be surprising nd disppointing. There ws onsiderble overlp in ll the mesured indies. Only two ptients with hroni pnretitis filed to hieve birbonte onentrtion higher thn 9 mmol/l, the ommonly epted riterion for bnormlity in stndrd duodenl dringe funtion tests. This suggests tht the muh lower figures normlly reported in duodenl juie result from the dilution of smller quntities of pnreti juie within the duodenum by bile nd other intestinl ontminnts. The differenes lso reflet the seletion of ptients. Mny studies of pnreti funtion in hroni pnretitis ontin high proportion with lifition of the glnd on PIZ 4 units Fig. 5 Totl protein nd mylse onentrtions in one norml subjet fter grded bolus intrvenous injetions of seretin, nd holeystokinin-pnreozymin (P/Z). Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

6 94 Protein Birb. Volume on. on. (mg/mi) (mmolll) 6 C)._ 6 5 _ r 6-5 F 4 F 3 F I v i. U... : Minutes N?CP CP N?CP CP N?CP CP Cu 4Cu 7Cu Seretin dose Fig. 7 Medin minute volume responses in ll ptients fter bolus injetions of seretin (medin levels shown by dotted line: N: norml, CP: hroni pnretitis,?cp: probble erly pnretitis). f nfusion of seretin + pnreozymin ( Cu/kg /h) plin rdiogrphs. This provides onvenient nd definite dignosti end-point, but is pplible only to the most severe ses. Only two ofour ptients C :... - U U C n U 4 r 3 F F iio F F 9 r 8 7 F 6 rb M.. Denyer nd P. B. Cotton Fig. 6 Medin volume, birbonte onentrtion nd protein onentrtion in ll norml subjets fter the infusion of seretin nd holeystokininpnreozymin (eh one CU/kg/h). N?CP CP Cu Seretin dose... t N?CPCP 4Cu N?CPCP 7Cu Fig. 8 Medin minute birbonte onentrtions in ll ptients fter grded bolus intrvenous injetions of seretin. Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

7 Pure pnreti juie studies in norml subjets nd ptients with hroni pnretitis Tble Differenes between norml subjets nd hroni pnretitis fter bolus injetions of seretin Seretin Group Volume p Birb on. p Birb output P Protein on. P Protein output P dose (CU) (mi/ min) (mmol/l) (mmol/ min) (mg/ml) (mg/jo min) N m =5-75 m =6 m= 8 m= 8 m =49.5 n= n= n= n=9 n=8 < NS < NS NS CP m= 93 m =7 m= m= 98 m =44-6 n=8 n=8 n=8 n=7 n= 7 4 N m =-8 m= 3 m= 9 m= -8 m =35-8 n =8 n =7 n =3 n =6 n =6 NS < 5 <5 NS NS CP m= 3-4 m= 3 m= 74 m=-6 m=6-3 n = n= n = n = n= 7 N m= 39. m= 3 m=495 m=.8 m= 87-4 n=9 n=8 n=8 n=8 n=8 <5 NS <5 NS <5 CP m =9. m =9 m= 75 m= 6 m =7- n = n = n = n = n = N: norml; CP: hroni pnretitis; m: medin vlue; n: number of ptients. _ - U U W._ U to 5 4 h 3 h _ 9 _ 8 _ 7 h M Cu Seretin. dose L v% nl.. N?CP CP N?CP CP 4Cu -- N?CP CP 7Cu Fig. 9 Pek birbonte onentrtions in one minute speimens in ll ptients fter grded bolus injetions of seretin. There re signifint differenes between norml subjets nd CP fter CU (p <.) nd 4 CU (p <.). No differenes were seen between norml ptients nd those with? erly hroni pnretiti6 t ny dose _4 o ( mf h N?CP CP Cu Seretin dose Fig !... m :... N?CP CP N?CP CP 4Cu 7 Cu Ten minute birbonte outputs in ll ptients fter grded bolus injetions of seretin. showed lifition; in one ptient there ws no flow of pnreti juie t ll fter deep nnultion nd seretin stimultion. Ptients with lifying hroni pnretitis do not require further dignosti test-the dignosis is lredy estblished. The dignosti problem ours in less severe ses nd the min purpose of this study ws to see whether 95 Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

8 96 M.. Denyer nd P. B. Cotton Tble 3 Medin vlues (+ rnges) in the groups of ptients in minute period strting minutes fter strt of seretin-holeystokinin-pnreozymin infusion Norml?CP CP Totl ptients Volume (ml/ min) ( ) ( ) (-35.9) Birbonte onn (mmol/l) (84-) (-6) (-5) Output (mmol/ min) (3-4-55) (.55-46) (-435) Protein onn (mg/ml) (.7-3.) (.8-5.6) (-3.3) Output (mg/ min) (46-93) (3-) (-78) pure pnreti juie funtion testing provided better disrimintion. This ws the reson for studying less severe, but definite, hroni pnretitis, nd lso group with probble hroni pnretitis t n even erlier stge. In the pure juie studies, the funtionl defet in ptients with hroni pnretitis ws more in volume prodution rther thn birbonte onentrting bility. Thus the dignosti pbilities of PPJ studies depend upon hieving omplete reovery of the sereted juie; while this is likely with low flow rtes, olletions re ertinly inomplete fter higher doses of stimulnts. ven if it were proved sfe to olude the pnreti dut orifie with blloon theter, some juie ould espe in mny ptients through Sntorini's dut nd the essory ppill. Furthermore, the resistne to flow down the long thin theter might itself exert n influene upon the pnreti response. It is diffiult to mesure the reovery frtion during pure juie studies, but this nd other tehnil spets re being exmined. Some ide of reovery n be gined by ompring the results of pure juie studies with those of stndrd duodenl spirtion studies in the sme ptients. In our own omprison in 3 ptients, the volumes obtined from the duodenum (unorreted for reovery of mrkers) exeeded those obtined from the pnreti dut in rtio of - to. fter orretion for duodenl reovery, the rtio ws -3 to. Some of this exess ws due to seretions other thn pnreti juie, s evidened by the ft tht the men birbonte onentrtion in pure juie exeeded tht of duodenl juie by men of 3 mmol/l (Denyer et l., 977). Like sourrou et l. (978), we found tht the birbonte output s mesured in pure juie onsiderbly exeeded tht in duodenl spirtes in pired studies. Totl protein onentrtions in these studies orrelted very losely with mylse levels. The finding of high protein onentrtions in the first juie speimens, nd trnsient inreses fter eh seretin stimulus re open to vrious explntions. It hs been suggested tht ptients with hroni pnretitis hve high juie protein onentrtions, leding to deposition of protein plugs, dut obtrution, nd lol lifition. tendeny towrds higher protein onentrtions ws seen in our studies fter low (physiologil) doses of seretin, but did not reh sttistil signifine (Tble 3). Detiled nlysis of individul enzymes nd protein frtions in pure juie is tehnilly omplex. We were surprised to find tive trypsin in the juie of some ptients; protein frtions degrded rpidly even on freezing. Sttements bout protein onstituents in pure juie n be epted only if restrited to studies in whih juie ws shown not to ontin tive trypsin immeditely on withdrwl. When these problems re overome, pure juie studies should provide n idel venue for further detiled reserh into onstituents whih my hve dignosti signifine, suh s ltoferrin (Colomb et l., 974; Fedil et l., 978), rinoembryoni ntigen (Kwnishi et l., 975b), isomylses (Skude nd lhre, 977), vrious protein frtions (Colomb et l., 974; lln nd White, 975), nd gmm glutmyl trnspeptidse (Renner nd Juttner, 976). Pure juie studies re tehnilly too diffiult for routine linil prtie, but the results obtined n demonstrte the reline to be pled upon simpler methods, nd led the serh for more speifi dignosti mrkers. The uthors grtefully knowledge the help gven in vrious prts of these studies by Dr. Miller, Stephnie Tough, Cthryn Corns, Jen Townson, nd Mri Kyne(Courtuld Instituteof Biohemistry, The Middlesex Hospitl nd Medil Shool) nd by Dr. Reuben, Dr R. Stern, nd Dr T. R. Hep. The reserh ws generously supported by the Wellome Trust, the North West Thmes Regionl Helth uthority, nd the Speil Trustees of The Middlesex Hospitl. Referenes llen, B. J., nd White, T. T. (975). refined ellulose ette-eletrophoreti tehnique for nlysis of humn pnreti juie. Biohemil Mediine,, Colomb,., stevenon, J. P., Figrell, C., Guy,., nd Srles, H. (974). Chrteristion of n dditionl protein in pnreti juie of men with hroni lifying pnretitis. Biohimi et Biophysi t, 34, Cotton, P. B. (977). RCP. Gut, 8, Cotton, P. B., Cremer, M., Robbereht, P., Deltenre, M., Ponder, B., nd Christophe, J. (974). Pure pnreti seretion olleted from within the pnreti dut t duodenosopy. Preliminry results of biohemil studies (bstrt). Gstroenterology, 66, 678. Denyer, M.., Cotton, P. B., Kyne, M., nd Miller,. Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.

9 Pure pnreti juie studies in norml subjets nd ptients with hroni pnretitis 97 (977). Pired pnreti funtion studies using pure pnreti juie nd duodenl juie. (bstrt). Gut, 8, 98. Domshke, S., Domshke, W., Rosh, W., Konturek, S. J., Wunsh,., nd Demling, L. (976). Birbonte nd yli MP ontent of pure humn pnreti juie in response to grded doses of syntheti seretin. Gstroenterology, 7, sourrou, J., Frexinos, J., nd Ribet,. (978). Biohemil studies of pnreti juie olleted by duodenl spirtion nd endosopi nnultion of the min pnreti dut. merin Journl of Digestive Diseses, 3, Fedil, S. S., Slmon, P. R., Hrvey, R. F., nd Red,.. (978). Rdioimmunossy of ltoferrin in pnreti juie s test for pnreti diseses. Lnet,, 8-8. Gregg, J.., nd Shrm, M. M. (976). The effet of seretin on pnreti juie flow rtes during endosopi nnultion of the min pnreti dut. (bstrt). Gstroenterology, 68, 95. Huemer, R. P., nd Lee, K. D. (97). utomted Lowry method for mirogrm protein determintion. nlytil Biohemistry, 37, Kwnishi, H., Sell, J.., nd Pollrd, H. M. (975). Combined endosopi pnreti fluid olletion nd retrogrde pnretogrphy in the dignosis of pnreti ner nd hroni pnretitis. Gstrointestinl ndosopy,, Kwnishi, H., Sell, J.., nd Pollrd, H. M. (975b). Crinoembryoni ntigen nd ytology of pnreti fluid. (bstrt). Gstroenterology, 66, 93. Pimstone, N. R. (965). study of the strh-iodine omplex: modified olorimetri miro determintion of mylse in biologi fluids. Clinil Chemistry,, Renner, I. G., nd Juttner, H. U. (976). new non-speifi mrker of erly pnreti disese. (bstrt). Gstroenterology, 7, 99. Skude, G., nd Ihre, T. (977). Isomylses in pnreti rinom nd hroni relpsing pnretitis. Sndinvin Journl of Gstroenterology,, Wrd,. S., nd Bloom, S. R. (974). The role of seretin in the inhibition of gstri seretin by intrduodenl id. Gut, 5, Wormsley, K. G. (968). Response to seretin in mn. Gstroenterology, 54, Gut: first published s.36/gut...89 on Februry 979. Downloded from on 8 November 8 by guest. Proteted by opyright.