- Email: [email protected]
Reversibility of exocrine pancreatic function
CORRESPONDENCE
Junel987
Measurement of Colonic Transit Dear Sir: We have read with interest the paper by Metcalf et al. (1)about the measurement of colonic transit time. This prompts US to add two comments. (a) We recently described a similar method using multiple markers (z] that led to comparable results. We used three different shapes of pellets to validate the method and to assess a possible reflux of pellets from distal to proximal colon (3). We think this method can be even more simplified for clinical use and suggest the use of only one type of pellet on days 1, 2, and 3. Neither the pellet’s shape nor the timing of ingestion are useful in calculating the colonic transit time with the formula used by Metcalf et al. and US:
MCT = 1.2 i n, i=1 Thus we used 20 cubic pellets (i.c.) ingested on day 1, 2, and 3 (total, 60 pellets) and we performed abdominal x-ray on day 4 and 7. (b) In addition to the study of Metcalf et al. we validated this method in 10 consecutive constipated patients (median whole colonic transit time = 78 h), and our results were in good agreement with those obtained by Ahran’s method (4). Thus, this method can be routinely used in constipated patients and we suggested that a third x-ray on day 10 is often useful when pellets are stil1 present on day 7 (Table 1).
Tabje
1.
Constipated n = 10
Correlation Between Whole and Segmental Colonic Transit Time in 10 Constipoted Patients Using Ahran’s Method and MultipleMarker Method Right colon
Left colon
r = 0.97
r = 0.94
Rectosigmoid r = 0.88
Whole colon r = 0.97
St.CHAUSSADE J.GUERRE D.COUTURIER Cochin Hospitai 27 Rue du Faubourg Saint Jacques F 75014 Paris, France Metcalf A, Phillips SF, Zinsmeister AR, MacCarty AL, Beart RW, Wolff BG. A simplified assessment of segmental colonic transit. Gastroenterology 1987;92:40-7. Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Mesure du temps de transit colique. Description et validation d’une nouvelle technique (abstr). Gastroenterol Clin Bio1 1985;9:29. Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Mesure du temps de transit colique: description and validation d’une nouvelle technique. Gastroenterol Clin Bio1 1986;10:385-9. Martelli G, Devroede G, Ahran P, Duguay C. Mechanisms of idiopathic constipation: outlet obstruction. Gastroenterology 1978;75:623-31. Reply.
We appreciate the comments of Dr. Chaussade and his colleagues on our recent paper (1). Further, we were reassured by their own findings (2) being quite similar to ours. A reference to their recent publication was included as a final point of discussion in our manuscript. We wish to reply to two points raised in their letter. First, we agree that different marker shapes are not essential for a clinical test of segmental colonic transit. Our main purpose in
2053
performing experiments with different shapes was to allow US to assess day-to-day transit in the same individual and, as discussed in our paper, this does not appear to be a variable of sufficient magnitude that it should greatly influence the clinical utility of the test. Thus, like them, we agree that the procedure can be simplified even further. The second point relates to the need for later films in constipated patients. As we discussed, abnormally slow transit can be readily documented by a 4-day film. Should more precise quantification be needed in those with very slow transit, we agree that films on day 7 or 10 wil1 provide this additional information. SF.PHILLIPS, M.D. Professor of Medicine, Mayo Medical Schooi Directer, General CJinicaJ Research Center Program Directer, Digestive Diseases Core Center Rochester, Minnesota 55905 1. Metcalf A, Phillips SF, Zinsmeister AR, MacCarty RL, Beart RW, Wolff BG. A simplified assessment of segmental colonic transit. Gastroenterology 1987;92:40-7. 2. Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Mesure du temps de transit colique: description and validation d’une nouvelle technique. Gastroenterol Clin Bio1 1986;10:385-9.
Reversibility of Exocrine Pancreatic Function Dear Sir: The paper published by Garcia-Puges et al. (1) took our special attention. They describe the possible reversibility of exocrine pancreatic insufficiency after decompression or abstinente in chronic pancreatitis, especially in patients selected for their low p-aminobenzoic acid urinary excretion and their high blood trypsin levels. The measure of the maxima1 exocrine secretion (bicarbonate and hydrolases) of the pancreas after secretin stimulation through a duodenal drainage or a pure pancreatic juice collection has been shown as the most reliable method to quantify the pancreatic function. In fact, the maxima1 bicarbonate output and concentration in pure pancreatic juice is the most sensitive test (2,3) and the best to reproduce (4,s) when investigating the pancreatic exocrine ability, even in case of obstructive pancreatitis. These criteria have been confirmed by using a discriminant analysis (linear and weighted combinations of various pure pancreatic juice tests after maxima1 secretin stimulation) when comparing them to increasing ductular abnormalities of pancreatography (6,7). Using this precise measure of the maxima1 pancreatic exocrine ability, 6 patients with painful alcoholic chronic pancreatitis and distal structure with upstream dilatation of the main pancreatic duet were studied before and after endoscopic relief of the obstruction (pancreatic large endoprosthesis or pancreatic sphincterotomy and stone extraction) (Figure 1). The maxima1 pancreatic exocrine function did not show any improvement within a mean follow-up period of 12 mo (2-26mo) although the pain disappeared immediately after endoscopic decompression in al1 6 patients. Steatorrhea was improved in 2 of 3 patients. Consequently we can state that clinical symptoms may be improved by allowing a free stream of pancreatic juice through obstruction in spite of altered pancreatic secretion. This purpose may be reached by surgery, by endoscopy in selected cases, or perhaps by abstinente only (which could allow disappearance of obstructive protein plugs). This fact may explain the recovery of p-aminobenzoic acid and high blood trypsin levels tests that are
2054
N
CORRESPONDENCE
+,. --
GASTROENTEROLOGY Vol. 92. No.
_-
-------------
6
J. DEVIERE, M.D. P. URBAIN, M.D. M. CRRMER, M.D.
O-
c-_-__-_---_-------i x---_
----__
-1.
b_
-----__+
Department of Gastroenterology ULB Hopital Erasme 808 Route de Lennik 1070 Brussels Belgium
~
-2. 7
1. Garcia-Puges -4 .?j
Y 2
Figure
5
8
11
%
76
TIME IMONTHSI
1. Evaluation of maxima1 pancreatic exocrine ability at the time of the endoscopic sphincterotomy of the pancreatie papilla (-----) or of the placement of an ] and after a mean follow-up of endoprosthesis (12 mo (2-26 mo). N = 2.55 X maxima1 bicarbonate output (milliequivalents per minute) + 0.03 X maxima1 bicarbonate concentration (milliequivalents per liter] 4.85, collected in the pure pancreatic juice after maximal secretin stimulation (1 CU/kg i.v.].
2.
3.
4.
5.
closely correlated to clinical symptoms (pain and steatorrhea) (1,8). We do not believe that the maxima1 exocrine ability could be improved by any treatment, as the cellular damage in chronic pancreatitis leads to acinar atrophy. Nevertheless, ductal decompression and abstinente are the only ways of preserving the residual pancreatic exocrine ability. Up to now, none of our 500 patients with alcoholic or idiopathic chronic pancreatitis has developed a further pancreatic cancer. In this pathology, secondary pancreatitis is only obstructive and should not be included in such studies, the pathogenesis and outcome being quite different.
6.
7. 8.
A, Navarro S, Ros E, et al. Reversibility of exocrine pancreatic failure in chronic pancreatitis. Gastroenterology 1986;91:17-24. Cremer M, Robberecht P, Toussaint J, et al. Pure pancreatic juice studies in man. Die Untersuchung der Bauchspeicheldruse, 1. Hamburger Medizinisches Symposium, 12 und 13 December, 1976:66-78. Denyer ME, Cotton PB. Pure pancreatic juice studies in normal subjects and patients with chronic pancreatitis. Gut 1979; 20:89-97. Escourrou J, Frexinos J, Ribet A. Etude de la secrétion pancréatique pure chez l’homme sous stimulation pancrbatique par secrétine-caeruléine. Gastroenterol Clin Bio1 1978;2:29-37. Domschke S, Domschke W, Rosch W, et al. Bicarbonate and cyclic AMP content of pure human pancreatic juice in response to graded doses of synthetic secretin. Gastroenterology 1976;70:533-6. Deviere J, Gulbis B, Delhaye M, et al. A study of the relationship between the canalar morphology and the exocrine function of the pancreas. A new method of linear estimation of the pancreatic function. Acts Endoscopica, 1985;15:403-14. Deviere J, Gulbis B, Delhaye M, et al. Pancreatic exocrine function and ductal morphology. Digestion 1986;35:16. lacobson DG, Currington C, Connery K, Toskes PP. Trypsinlike immunoreactivity as a test for pancreatic insufficiency. N Eng1 J Med 1984;310:1307-9.
Junel987
Measurement of Colonic Transit Dear Sir: We have read with interest the paper by Metcalf et al. (1)about the measurement of colonic transit time. This prompts US to add two comments. (a) We recently described a similar method using multiple markers (z] that led to comparable results. We used three different shapes of pellets to validate the method and to assess a possible reflux of pellets from distal to proximal colon (3). We think this method can be even more simplified for clinical use and suggest the use of only one type of pellet on days 1, 2, and 3. Neither the pellet’s shape nor the timing of ingestion are useful in calculating the colonic transit time with the formula used by Metcalf et al. and US:
MCT = 1.2 i n, i=1 Thus we used 20 cubic pellets (i.c.) ingested on day 1, 2, and 3 (total, 60 pellets) and we performed abdominal x-ray on day 4 and 7. (b) In addition to the study of Metcalf et al. we validated this method in 10 consecutive constipated patients (median whole colonic transit time = 78 h), and our results were in good agreement with those obtained by Ahran’s method (4). Thus, this method can be routinely used in constipated patients and we suggested that a third x-ray on day 10 is often useful when pellets are stil1 present on day 7 (Table 1).
Tabje
1.
Constipated n = 10
Correlation Between Whole and Segmental Colonic Transit Time in 10 Constipoted Patients Using Ahran’s Method and MultipleMarker Method Right colon
Left colon
r = 0.97
r = 0.94
Rectosigmoid r = 0.88
Whole colon r = 0.97
St.CHAUSSADE J.GUERRE D.COUTURIER Cochin Hospitai 27 Rue du Faubourg Saint Jacques F 75014 Paris, France Metcalf A, Phillips SF, Zinsmeister AR, MacCarty AL, Beart RW, Wolff BG. A simplified assessment of segmental colonic transit. Gastroenterology 1987;92:40-7. Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Mesure du temps de transit colique. Description et validation d’une nouvelle technique (abstr). Gastroenterol Clin Bio1 1985;9:29. Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Mesure du temps de transit colique: description and validation d’une nouvelle technique. Gastroenterol Clin Bio1 1986;10:385-9. Martelli G, Devroede G, Ahran P, Duguay C. Mechanisms of idiopathic constipation: outlet obstruction. Gastroenterology 1978;75:623-31. Reply.
We appreciate the comments of Dr. Chaussade and his colleagues on our recent paper (1). Further, we were reassured by their own findings (2) being quite similar to ours. A reference to their recent publication was included as a final point of discussion in our manuscript. We wish to reply to two points raised in their letter. First, we agree that different marker shapes are not essential for a clinical test of segmental colonic transit. Our main purpose in
2053
performing experiments with different shapes was to allow US to assess day-to-day transit in the same individual and, as discussed in our paper, this does not appear to be a variable of sufficient magnitude that it should greatly influence the clinical utility of the test. Thus, like them, we agree that the procedure can be simplified even further. The second point relates to the need for later films in constipated patients. As we discussed, abnormally slow transit can be readily documented by a 4-day film. Should more precise quantification be needed in those with very slow transit, we agree that films on day 7 or 10 wil1 provide this additional information. SF.PHILLIPS, M.D. Professor of Medicine, Mayo Medical Schooi Directer, General CJinicaJ Research Center Program Directer, Digestive Diseases Core Center Rochester, Minnesota 55905 1. Metcalf A, Phillips SF, Zinsmeister AR, MacCarty RL, Beart RW, Wolff BG. A simplified assessment of segmental colonic transit. Gastroenterology 1987;92:40-7. 2. Chaussade S, Roche H, Khyari A, Couturier D, Guerre J. Mesure du temps de transit colique: description and validation d’une nouvelle technique. Gastroenterol Clin Bio1 1986;10:385-9.
Reversibility of Exocrine Pancreatic Function Dear Sir: The paper published by Garcia-Puges et al. (1) took our special attention. They describe the possible reversibility of exocrine pancreatic insufficiency after decompression or abstinente in chronic pancreatitis, especially in patients selected for their low p-aminobenzoic acid urinary excretion and their high blood trypsin levels. The measure of the maxima1 exocrine secretion (bicarbonate and hydrolases) of the pancreas after secretin stimulation through a duodenal drainage or a pure pancreatic juice collection has been shown as the most reliable method to quantify the pancreatic function. In fact, the maxima1 bicarbonate output and concentration in pure pancreatic juice is the most sensitive test (2,3) and the best to reproduce (4,s) when investigating the pancreatic exocrine ability, even in case of obstructive pancreatitis. These criteria have been confirmed by using a discriminant analysis (linear and weighted combinations of various pure pancreatic juice tests after maxima1 secretin stimulation) when comparing them to increasing ductular abnormalities of pancreatography (6,7). Using this precise measure of the maxima1 pancreatic exocrine ability, 6 patients with painful alcoholic chronic pancreatitis and distal structure with upstream dilatation of the main pancreatic duet were studied before and after endoscopic relief of the obstruction (pancreatic large endoprosthesis or pancreatic sphincterotomy and stone extraction) (Figure 1). The maxima1 pancreatic exocrine function did not show any improvement within a mean follow-up period of 12 mo (2-26mo) although the pain disappeared immediately after endoscopic decompression in al1 6 patients. Steatorrhea was improved in 2 of 3 patients. Consequently we can state that clinical symptoms may be improved by allowing a free stream of pancreatic juice through obstruction in spite of altered pancreatic secretion. This purpose may be reached by surgery, by endoscopy in selected cases, or perhaps by abstinente only (which could allow disappearance of obstructive protein plugs). This fact may explain the recovery of p-aminobenzoic acid and high blood trypsin levels tests that are
2054
N
CORRESPONDENCE
+,. --
GASTROENTEROLOGY Vol. 92. No.
_-
-------------
6
J. DEVIERE, M.D. P. URBAIN, M.D. M. CRRMER, M.D.
O-
c-_-__-_---_-------i x---_
----__
-1.
b_
-----__+
Department of Gastroenterology ULB Hopital Erasme 808 Route de Lennik 1070 Brussels Belgium
~
-2. 7
1. Garcia-Puges -4 .?j
Y 2
Figure
5
8
11
%
76
TIME IMONTHSI
1. Evaluation of maxima1 pancreatic exocrine ability at the time of the endoscopic sphincterotomy of the pancreatie papilla (-----) or of the placement of an ] and after a mean follow-up of endoprosthesis (12 mo (2-26 mo). N = 2.55 X maxima1 bicarbonate output (milliequivalents per minute) + 0.03 X maxima1 bicarbonate concentration (milliequivalents per liter] 4.85, collected in the pure pancreatic juice after maximal secretin stimulation (1 CU/kg i.v.].
2.
3.
4.
5.
closely correlated to clinical symptoms (pain and steatorrhea) (1,8). We do not believe that the maxima1 exocrine ability could be improved by any treatment, as the cellular damage in chronic pancreatitis leads to acinar atrophy. Nevertheless, ductal decompression and abstinente are the only ways of preserving the residual pancreatic exocrine ability. Up to now, none of our 500 patients with alcoholic or idiopathic chronic pancreatitis has developed a further pancreatic cancer. In this pathology, secondary pancreatitis is only obstructive and should not be included in such studies, the pathogenesis and outcome being quite different.
6.
7. 8.
A, Navarro S, Ros E, et al. Reversibility of exocrine pancreatic failure in chronic pancreatitis. Gastroenterology 1986;91:17-24. Cremer M, Robberecht P, Toussaint J, et al. Pure pancreatic juice studies in man. Die Untersuchung der Bauchspeicheldruse, 1. Hamburger Medizinisches Symposium, 12 und 13 December, 1976:66-78. Denyer ME, Cotton PB. Pure pancreatic juice studies in normal subjects and patients with chronic pancreatitis. Gut 1979; 20:89-97. Escourrou J, Frexinos J, Ribet A. Etude de la secrétion pancréatique pure chez l’homme sous stimulation pancrbatique par secrétine-caeruléine. Gastroenterol Clin Bio1 1978;2:29-37. Domschke S, Domschke W, Rosch W, et al. Bicarbonate and cyclic AMP content of pure human pancreatic juice in response to graded doses of synthetic secretin. Gastroenterology 1976;70:533-6. Deviere J, Gulbis B, Delhaye M, et al. A study of the relationship between the canalar morphology and the exocrine function of the pancreas. A new method of linear estimation of the pancreatic function. Acts Endoscopica, 1985;15:403-14. Deviere J, Gulbis B, Delhaye M, et al. Pancreatic exocrine function and ductal morphology. Digestion 1986;35:16. lacobson DG, Currington C, Connery K, Toskes PP. Trypsinlike immunoreactivity as a test for pancreatic insufficiency. N Eng1 J Med 1984;310:1307-9.