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Isolated exocrine pancreas insufficiency
April 1995
PREOPERATIVE IMAGING TECHNIQUES ACCURATELY ASSESS THE LOCATION AND EXTENT OF INTRADUCTAL PANCREATIC TUMORS (IDTP). Ponsot P. Ruszniewski P, Barbe L, *Molas G, **Vilgrain V, Bernades P. Departments of Gastroenterology, *Pathology and **Radiology. Beaujon Hospital, 92118 Clichy Cedex, France. In patients with IDTP, the choice of the pancreatic resection procedure depends on the location and extent of the adenomatous proliferation~ The latter parameters may be difficult to assess, because of an infiltrative tumoral pattern recognized but on the resection specimen. Moreover, mncin hypersecretion may be responsible for pancreatic duct dilatation and filling defects, mimicking intraductal adenomas. The aim of this study was to evaluate the accuracy of preoperative imaging procedures, i.e. the combination of abdominal CT scan, duodenoscopy and pancreatic retrograde endoscopy (PRE), to assess the extent of IDTP. Patients (ots~ and m e t h o d s . 7 pts (5 M, 2 F, median age 61 years, range 42-84) presenting with IDTP located in the pancreatic head (n = 5, two of whom with single adenomas), tail (n = 1) or diffuse (n = 1) were studied. Final diagnosis was obtained by laparot0my in all pts [cephalic duodenopancreatectomy in 4, caudal pancreatectomy in 1, total pancreatectomy in 1, resection of adenomas of the main pancreatic duct (MPD) and wirsungojejunal anastomosis in 1]. All pta underwent the previously mentioned preoperative imaging techniques ; 4 also underwent endoscopic ultrasonography (EUS). Median post-operative follow-up with CT scan and EUS was 4.7 years (range 2-9). Results. Segmental anomalies of the pancreatic ducts were found in 6/7 pts (group I). Cystic dilatation of the pancreatic ducts was observed in 3/6 cases (head : 2 ; tail : 1) ; filling defects of the cephalic part of the MPD, due to mucin hypersecretion (n = 2) or to an adenoma (n = 1, associated with MPD dilatation) were noticed in 3 pts. Diffuse or irregular dilatation of the MPD was found in 1/7 pt. Histological examination confLrmed the segmental distribution of IDTP in all group I pts ; no post-operative recurrence was observed in the 5 pts with pancreatic resection. In the only pt with a diffuse IDTP pattern, total pancreatectomy found adenomas throughout the MPD. Conclusions. IDTP may be single, segmental or less often diffuse. They are accurately recognized by preoperative imaging techniques, despite the mucin hypersecrefion and the microscopic pattern of some tumors.
ISOLATED EXOCRINE PANCREAS INSUFFICIENCY. Simon S. Rabinowitz, Ph.D., M.D. Division of Gastroenterology, Children's Medical Center of Brooklyn, Brooklyn, NY 11203. Backeround: Cystic Fibrosis (CF) is the most common etiology for pancreatic insufficiency in all children and the most common genetic abnormality associated with considerable morbidity and permature mortality in Caucasians. Mutations in a single gene are responsible for the protean phenotypic manifestations. The gene has been sequenced and codes for a membrane protein that serves as a chloride channel. Clinical Summary: Two urn'elated school aged children from different ethnic backgrounds were investigated for steatorrhea, (fat malabsorption 16% and 23%). Neither had failure to thrive, cyclic neutropenia, short stature, bony abnormalities , sideroblastic anemia, nasal abnormalities, a past history of pacreatitis or family members with pancreatitis. Duodenal fluid was obtained endoscopically and revealed depressed activity of all pancreatic exocrine enzymes studied, normal pH, and normal protein content in both patients. Both had a clinical response to pancreatic enzyme replacement therapy. Each had normal or near normal, sweat chlorides on two occasions, normal pulmonary function tests, and normal duodenal biopsies without evidence of villus compromise or inspissated secretions. CT scans in both girls showed pancreatic atrophy similar to the radiographic appearance noted in cystic fibrosis, as well as fatty infiltration of their livers. Liver biopsies showed steatosis without necrosis, bile duct plugging, or bile duct proliferation. Disida scans in both had normal intrahepatic and extrahepatic clearance. Conclusions: A rare phenotypic expression of isolated pancreatic insufficiency is described. The radiographic appearance is suggestive of pancreatic CF, hut there is no evidence of pulmonary, intestinal, biliary, or sweat gland involvement. Arrangements are being made to perform CF gene analyses on these children. It will be intriguing to determine if this unusual phenotype represents a novel gene defect in the CF gene or another acinar membrane channel gene.
Pancreatic Disorders
A385
• DEMONSTRATION OF THE PATHOGENETIC EFFECTS OF CHRONIC ETHANOL IN A RAT MODEL OF DUCT-INJURED CHRONIC PANCREATITIS. V. Puig-DivI, X. Molero. A. Salas*, J-R Malagelada. Digestive System Research Unit, Hospital General Vail d'Hebron, Barcelona. "Pathology Department, Hospital Mama, Terrassa, Spain. Alcoholism is commonly associated with chronic pancreatitis. However, chronic ethanol feeding fails to induce pancreatitis in experimental animals. We hypothesized that ethanol would manifest its pathogenetie effects on duct-injured pancreas. Hence, in Protocol I we established a chronic pancreatitis model via laparotomy and direct instination of 0.4 ml of trinitrobenzene sulfonic acid (TNB) 2% in PBS-10% ethanol (pH 8) into the pancreatic ducts under a controlled pressure system (n=58). Controls underwent the same procedure with vehicle (n=34). Under Protocol II, TNB-treated rats (n=16) received 4 ml of 20% ethanol daily by gastric cannula. Additional 20% ethanol was consumed in drinking water. Vehicle rats received ethanol in the same way and served as reference (n=7). Pathological examination was performed at 48 h and at 3, 4 and 5 weeks, as appropriate. Amytasemia and oral glucose tolerance test (OGTT) (2 g/Kg) were determined on the fifth week. Results: Protocol I: At 48 h TNBtreated rats showed severe necrotizing pancreatitis associated with amylasemia rise to 37.48 + 8.8 U/ml and a mortality rate of 31%. Control rats had an amylasemia of 10.8 +3 U/ml (p < 0.01), minimal leucocyte infiltrates in the gland and a 10% mortality. At 3, 4 and 5 weeks, pathological examination was normal in vehicle rats. Chronic lesions developed in all TNB-treated rats and consisted in periductal and intralobular fibrosis, acute and chronic inflammatory infiltrates, duct stenosis and gland atrophy. Islets were preserved. Weight gain slowed during the second and third week (398+13 and 422+14 gr) as compared to vehicle (458__. 16 and 482+11; p<0.01 for both time points) but recovered thereafter. Fasting glucose and OGTT (111+4 and 197+26 mg/dl) were similar in TNB and control rats (984-3 and 1724-4 mg/dl; n.s.). Protocol II: Ethanol feeding to TNB-treated rats increased fasting glucose (1414-5 mg/dl) and OGTT (376+_41 mg/dl; p < 0.001) as well as amylasemia (6.2_+0.3 vs 4.24-0.2 U(ml; p < 0.001). Larger areas of gland atrophy were observed with striking disruption of the normal architecture of the islets. Ethanol also impaired weight gain from the first (2894-9 gr) through the fifth week (3704-7 g; p<0.001 vs TNB only rats). Vehicle rats fed with ethanol showed no morphologic or biochemical disturbances and their weight gain was significantly greater than TNB+ethanol rats. Conclusion: Chronic pancreatitis resembling human disease may be induced by intraductal TNB. In this model ethanol feeding clearly aggravates the morphological and functional evolution of the disease.
• NOVEL CD44v6 I S O F O R M O V E R E X P R E S S E D IN M E T A S T A S E S OF PANCREATIC ADENOCARCINOMA. Christovher L N. Rall and Anil K. Rustgi. Gastrointestinal Unit, Massac[msetts General Hospital, Boston, MA. CD44 is the major transmembrane adhesion molecule which binds hyaluronate. The gene encoding CD44 is found on chromosome l i p and comprises 19 exons. Differential splicing of the nine extracellular juxtamembranous exons (v2-10) generates the major isoforms of CD44. The major CD44 isoform found on hematopoetic cells contains none of the variably expressed exons, while the major isoform expressed on epithelial cells contains exons v8-10. Metastasis specific isoforms of CD44 were first documented in a model of rat pancreatic adenocarcinoma (v4-7) and subsequently in human colonic (v8-10) and gastric (v9) adenocarcinomas. This study is the first characterization of CD44 isoforms in primary and metastatic pancreatic adenocarcinoms. METHODS: mRNA was isolated from specimens of 15 primary and 6 metastatic pancreatic adenocareinomas as Well as in 6 control pancreas specimens. The CD44 isoforms in were analyzed by two different methods. Reverse-transcriptase polymerase chain reaction (RT-PCR) using primers flanking the major extracellular juxtamembranous splice site were used to generate all CD44 isoforms. 5111 of the PCR product were amplified an additional 5 cycles to incorporate ~-32p-dCTP to allow analysis of the major CD44 isoforms on 8% polyacrylamide gel electrophoresis. In addition, hybridization with a 32p labeled 129 bp v6 exon probe performed on a Southern blot of another 5 I11 of the PCR products demonstrated all v6 containing isoforms. R E S U L T S : No differences in the expression of v8-10 exons were found among the primary and metastatic cancers, and control specimens of pancreas; however, 6/15 of the primaries, and 4/6 of the metastases contained exon v6 while found in only 2/6 of the controls. CONCLUSIONS: The v4-7 isoform seen in rat pancreatic adenocarcinoma was not detected in human pancreatic adenocareinoma. Interestingly enough, the v8-10 isoform is not differentially expressed, in contrast to the observation in gastric and colon cancers. A novel CD44v6 isoform is overexpressed in human pancreatic adenocarcinoma.
PREOPERATIVE IMAGING TECHNIQUES ACCURATELY ASSESS THE LOCATION AND EXTENT OF INTRADUCTAL PANCREATIC TUMORS (IDTP). Ponsot P. Ruszniewski P, Barbe L, *Molas G, **Vilgrain V, Bernades P. Departments of Gastroenterology, *Pathology and **Radiology. Beaujon Hospital, 92118 Clichy Cedex, France. In patients with IDTP, the choice of the pancreatic resection procedure depends on the location and extent of the adenomatous proliferation~ The latter parameters may be difficult to assess, because of an infiltrative tumoral pattern recognized but on the resection specimen. Moreover, mncin hypersecretion may be responsible for pancreatic duct dilatation and filling defects, mimicking intraductal adenomas. The aim of this study was to evaluate the accuracy of preoperative imaging procedures, i.e. the combination of abdominal CT scan, duodenoscopy and pancreatic retrograde endoscopy (PRE), to assess the extent of IDTP. Patients (ots~ and m e t h o d s . 7 pts (5 M, 2 F, median age 61 years, range 42-84) presenting with IDTP located in the pancreatic head (n = 5, two of whom with single adenomas), tail (n = 1) or diffuse (n = 1) were studied. Final diagnosis was obtained by laparot0my in all pts [cephalic duodenopancreatectomy in 4, caudal pancreatectomy in 1, total pancreatectomy in 1, resection of adenomas of the main pancreatic duct (MPD) and wirsungojejunal anastomosis in 1]. All pta underwent the previously mentioned preoperative imaging techniques ; 4 also underwent endoscopic ultrasonography (EUS). Median post-operative follow-up with CT scan and EUS was 4.7 years (range 2-9). Results. Segmental anomalies of the pancreatic ducts were found in 6/7 pts (group I). Cystic dilatation of the pancreatic ducts was observed in 3/6 cases (head : 2 ; tail : 1) ; filling defects of the cephalic part of the MPD, due to mucin hypersecretion (n = 2) or to an adenoma (n = 1, associated with MPD dilatation) were noticed in 3 pts. Diffuse or irregular dilatation of the MPD was found in 1/7 pt. Histological examination confLrmed the segmental distribution of IDTP in all group I pts ; no post-operative recurrence was observed in the 5 pts with pancreatic resection. In the only pt with a diffuse IDTP pattern, total pancreatectomy found adenomas throughout the MPD. Conclusions. IDTP may be single, segmental or less often diffuse. They are accurately recognized by preoperative imaging techniques, despite the mucin hypersecrefion and the microscopic pattern of some tumors.
ISOLATED EXOCRINE PANCREAS INSUFFICIENCY. Simon S. Rabinowitz, Ph.D., M.D. Division of Gastroenterology, Children's Medical Center of Brooklyn, Brooklyn, NY 11203. Backeround: Cystic Fibrosis (CF) is the most common etiology for pancreatic insufficiency in all children and the most common genetic abnormality associated with considerable morbidity and permature mortality in Caucasians. Mutations in a single gene are responsible for the protean phenotypic manifestations. The gene has been sequenced and codes for a membrane protein that serves as a chloride channel. Clinical Summary: Two urn'elated school aged children from different ethnic backgrounds were investigated for steatorrhea, (fat malabsorption 16% and 23%). Neither had failure to thrive, cyclic neutropenia, short stature, bony abnormalities , sideroblastic anemia, nasal abnormalities, a past history of pacreatitis or family members with pancreatitis. Duodenal fluid was obtained endoscopically and revealed depressed activity of all pancreatic exocrine enzymes studied, normal pH, and normal protein content in both patients. Both had a clinical response to pancreatic enzyme replacement therapy. Each had normal or near normal, sweat chlorides on two occasions, normal pulmonary function tests, and normal duodenal biopsies without evidence of villus compromise or inspissated secretions. CT scans in both girls showed pancreatic atrophy similar to the radiographic appearance noted in cystic fibrosis, as well as fatty infiltration of their livers. Liver biopsies showed steatosis without necrosis, bile duct plugging, or bile duct proliferation. Disida scans in both had normal intrahepatic and extrahepatic clearance. Conclusions: A rare phenotypic expression of isolated pancreatic insufficiency is described. The radiographic appearance is suggestive of pancreatic CF, hut there is no evidence of pulmonary, intestinal, biliary, or sweat gland involvement. Arrangements are being made to perform CF gene analyses on these children. It will be intriguing to determine if this unusual phenotype represents a novel gene defect in the CF gene or another acinar membrane channel gene.
Pancreatic Disorders
A385
• DEMONSTRATION OF THE PATHOGENETIC EFFECTS OF CHRONIC ETHANOL IN A RAT MODEL OF DUCT-INJURED CHRONIC PANCREATITIS. V. Puig-DivI, X. Molero. A. Salas*, J-R Malagelada. Digestive System Research Unit, Hospital General Vail d'Hebron, Barcelona. "Pathology Department, Hospital Mama, Terrassa, Spain. Alcoholism is commonly associated with chronic pancreatitis. However, chronic ethanol feeding fails to induce pancreatitis in experimental animals. We hypothesized that ethanol would manifest its pathogenetie effects on duct-injured pancreas. Hence, in Protocol I we established a chronic pancreatitis model via laparotomy and direct instination of 0.4 ml of trinitrobenzene sulfonic acid (TNB) 2% in PBS-10% ethanol (pH 8) into the pancreatic ducts under a controlled pressure system (n=58). Controls underwent the same procedure with vehicle (n=34). Under Protocol II, TNB-treated rats (n=16) received 4 ml of 20% ethanol daily by gastric cannula. Additional 20% ethanol was consumed in drinking water. Vehicle rats received ethanol in the same way and served as reference (n=7). Pathological examination was performed at 48 h and at 3, 4 and 5 weeks, as appropriate. Amytasemia and oral glucose tolerance test (OGTT) (2 g/Kg) were determined on the fifth week. Results: Protocol I: At 48 h TNBtreated rats showed severe necrotizing pancreatitis associated with amylasemia rise to 37.48 + 8.8 U/ml and a mortality rate of 31%. Control rats had an amylasemia of 10.8 +3 U/ml (p < 0.01), minimal leucocyte infiltrates in the gland and a 10% mortality. At 3, 4 and 5 weeks, pathological examination was normal in vehicle rats. Chronic lesions developed in all TNB-treated rats and consisted in periductal and intralobular fibrosis, acute and chronic inflammatory infiltrates, duct stenosis and gland atrophy. Islets were preserved. Weight gain slowed during the second and third week (398+13 and 422+14 gr) as compared to vehicle (458__. 16 and 482+11; p<0.01 for both time points) but recovered thereafter. Fasting glucose and OGTT (111+4 and 197+26 mg/dl) were similar in TNB and control rats (984-3 and 1724-4 mg/dl; n.s.). Protocol II: Ethanol feeding to TNB-treated rats increased fasting glucose (1414-5 mg/dl) and OGTT (376+_41 mg/dl; p < 0.001) as well as amylasemia (6.2_+0.3 vs 4.24-0.2 U(ml; p < 0.001). Larger areas of gland atrophy were observed with striking disruption of the normal architecture of the islets. Ethanol also impaired weight gain from the first (2894-9 gr) through the fifth week (3704-7 g; p<0.001 vs TNB only rats). Vehicle rats fed with ethanol showed no morphologic or biochemical disturbances and their weight gain was significantly greater than TNB+ethanol rats. Conclusion: Chronic pancreatitis resembling human disease may be induced by intraductal TNB. In this model ethanol feeding clearly aggravates the morphological and functional evolution of the disease.
• NOVEL CD44v6 I S O F O R M O V E R E X P R E S S E D IN M E T A S T A S E S OF PANCREATIC ADENOCARCINOMA. Christovher L N. Rall and Anil K. Rustgi. Gastrointestinal Unit, Massac[msetts General Hospital, Boston, MA. CD44 is the major transmembrane adhesion molecule which binds hyaluronate. The gene encoding CD44 is found on chromosome l i p and comprises 19 exons. Differential splicing of the nine extracellular juxtamembranous exons (v2-10) generates the major isoforms of CD44. The major CD44 isoform found on hematopoetic cells contains none of the variably expressed exons, while the major isoform expressed on epithelial cells contains exons v8-10. Metastasis specific isoforms of CD44 were first documented in a model of rat pancreatic adenocarcinoma (v4-7) and subsequently in human colonic (v8-10) and gastric (v9) adenocarcinomas. This study is the first characterization of CD44 isoforms in primary and metastatic pancreatic adenocarcinoms. METHODS: mRNA was isolated from specimens of 15 primary and 6 metastatic pancreatic adenocareinomas as Well as in 6 control pancreas specimens. The CD44 isoforms in were analyzed by two different methods. Reverse-transcriptase polymerase chain reaction (RT-PCR) using primers flanking the major extracellular juxtamembranous splice site were used to generate all CD44 isoforms. 5111 of the PCR product were amplified an additional 5 cycles to incorporate ~-32p-dCTP to allow analysis of the major CD44 isoforms on 8% polyacrylamide gel electrophoresis. In addition, hybridization with a 32p labeled 129 bp v6 exon probe performed on a Southern blot of another 5 I11 of the PCR products demonstrated all v6 containing isoforms. R E S U L T S : No differences in the expression of v8-10 exons were found among the primary and metastatic cancers, and control specimens of pancreas; however, 6/15 of the primaries, and 4/6 of the metastases contained exon v6 while found in only 2/6 of the controls. CONCLUSIONS: The v4-7 isoform seen in rat pancreatic adenocarcinoma was not detected in human pancreatic adenocareinoma. Interestingly enough, the v8-10 isoform is not differentially expressed, in contrast to the observation in gastric and colon cancers. A novel CD44v6 isoform is overexpressed in human pancreatic adenocarcinoma.