Serum-induced lysis ofPseudomonas aeruginosa

The sensitivity of 12Pseudomonas aeruginosa strains (5 mucoid and 7 non-mucoid strains) to serum and the interaction of these strains with the complement system was studied. Five strains (4 mucoid and 1 non-mucoid strains) were lysed in 20 % normal serum as measured by the release of rediolabelled material from³H-adenine labelled bacteria. Three of these strains were also lysed in MgEGTA chelated serum. All strains activated complement via the classical pathway, and six strains were able to activate the alternative complement pathway as well. Slime production did not interfere with bacteriolysis and complement consumption.     

Granulomatous pancreatitis - granulomas in chronic pancreatitis

Summary Granulomatous pancreatitis can be described only in infectious granulomas and pancreatic involvement by systemic granulomatosis. The presence of classical chronic tryptic pancreatitis in addition to individual sarcoidosis granulomas in one of our cases of sarcoidosis, shows that pancreatitis in a patient with generalized granulomatosis should not necessarily be considered granulomatous pancreatitis. A variety of foreign-body granulomas found in the pancreas may be explained by previous surgical operations, and other foreign bodies introducted iatrogenically. Occasionally, the pancreas in chronic pancreatitis contains granulomas that must be considered foreign body granulomas, although the causal foreign body cannot be identified. We believe that we can identify inspissated secretion that has passed out of the ductal system into the interstitium as the foreign body responsible. It is not possible to establish whether such iatrogenic measures as manipulations of the duct with back-up of the secretion within the ductal system, has any causative involvement in this secretion oedema. However, the absorption of the individual parenchymal secretions is impaired to such a degree that any extravasated remain in situ for a lengthy period. The absorption of the aqueous constituents leads to inspissation, so that it can finally be absorbed only through the formation of foreign body granulomas.The same granulogenic property in highly scarred pancreatic parenchyma is also recognizable in the abnormal degradation mode of normally absorbable Ethibloc, and in the excessive arterial and periarterial reactions following angiography.The presence of granulomas within the parenchyma of the pancreas in chronic pancreatitis, many of which have been induced by endogenous and/or exogenous foreign bodies would not lead us to refer to a granulomatous pancreatitis, since the remaining sections of the parenchyma manifest typical necroses and scar foci of chronic pancreatitis. We would characterize these granulomas by the term granulomas in chronic pancreatitis, and differentiate this from granulomatous pancreatitis.Dedicated to Prof. G. Seifert on the occasion of his 65th birthday     

Epithelial dysplasias in chronic pancreatitis

Summary The present 280 specimens of chronic pancreatitis were examined to determine the type and frequency of epithelial dysplasia of the duct system. The epithelial dysplasias were divided into 3 degrees of severity according to cytological and histological criteria. Dysplasia was demonstrable in 40.1% of the 280 specimens. Of these 32.9% were classified as dysplasia grade I and 7.1% as dysplasia grade II. Dysplasia grade III did not occur.The epithelial proliferations were correlated with the topography, the stage of the scarring and the degree of obstruction of pancreatic secretion. An increase in dysplasia was evident in relation to the stage of the scarring and to the obstruction of secretory outflow. In correlation with the topography of the chronic pancreatitis there was the highest frequency of epithelial dysplasias in uniformly scarred glands (47.7%). Papillary and pseudopapillary hyperplasias with atypia were demonstrated in 17.9 vs. 4.5% of the cases with epithelial proliferations.Supported by The Wilhelm-Sander Foundation, Neustadt/Donau     

Pancreolauryl test in chronic pancreatitis

Summary The pancreolauryl test was performed in 30 subjects with chronic pancreatitis, in order to evaluate its behavior in relation to the duration of the clinical history and the presence of pancreatic calcifications, diabetes mellitus, jaundice, and pancreatic pseudocysts.A significant inverse linear correlation was found between the onset of symptoms and FDL test values. While calcifications and diabetes were present in patients with both normal and abnormal test results, those with pseudocysts or jaundice always had pathological results.Abbreviations FDL Test Fluorescein-dilaurate test Supported in part by Centro Regionale di Alta Specializzazione per lo Studio delle Malattie del Fegato e del Pancreas. Conducted under the auspices of the R. Farini Association for Gastroenterological Research     

HLA antigens in chronic pancreatitis

Since immunological and hereditary factors may be important in chronic pancreatitis, histocompatibility antigens of classes I and II were studied in 50 British Caucasian patients, after exclusion of insulin-dependent diabetics for whom HLA associations are recognised. Chronic pancreatitis was defined by at least two independent criteria, and only subjects with alcohol-related and idiopathic disease were included. In 22 patients (21 male), weekly ethanol intake had chronically exceeded 100 g (usually substantially so); the remaining 28 had idiopathic chronic pancreatitis (ICP). Twenty patients (40%) had autoantibodies, in 11 (22%) to gastric parietal cells. Nine of those with ICP (three male) had parietal cell antibody, more than expected for the age/sex distribution. There were overall increased frequencies of HLA Cw5 and B44. In ICP there were increased frequencies of HLA A25 and Cw1, and a decreased frequency of B7. In patients with alcohol-related disease there were increased frequencies of Cw5 (50.0% vs control 15.9%), B44 (54.5% vs 29.4%), and DR4 (61.1% vs 33.6%). The increased frequency of Cw5 in alcohol-related disease alone remained significant after correction (p less than 0.05). A hypothesis that hereditary and possibly immunological factors may contribute to the aetiology of chronic pancreatitis is supported.     

Uncommon types of chronic pancreatitis

Alcoholic chronic pancreatitis and obstructive chronic pancreatitis are the most frequent and the better characterized types of pancreatitis. Recent advances in biology and genetics have brought new insights into the understanding of rare forms of chronic pancreatitis such as tropical chronic pancreatitis, hereditary chronic pancreatitis and chronic pancreatitis in cystic fibrosis. Some other rare forms of chronic pancreatitis have been identified: eosinophilic chronic pancreatitis, chronic pancreatitis after radiotherapy or during hypercalcemia, minimal change chronic pancreatitis and chronic pancreatitis associated with gut diseases or connectivitis. Recently, a particular form of non alcoholic chronic pancreatitis with duct destruction has been described often presenting as a pancreatic mass, leading in some cases to surgical resection of the pancreas. New insights into the understanding of chronic pancreatitis lead to new physiopathological concepts, and many arguments suggest that combined factors may lead to chronic inflammatory lesions of the pancreas.     

Clinico-diagnostic aspects of chronic pancreatitis

Chronic pancreatitis are mainly classified as chronic calcifying pancreatitis (CCP) and chronic obstructive pancreatitis (COP). The first classification was performed in 1963 and reproposed in 1984. Clinical symptoms and natural history of chronic pancreatitis are presented. Pre-operative clinico-radiological findings may be pathognomonic of the disease. Endoscopic retrograde cholangio-pancreatography (ERCP) and per-operative pancreatography and cholangiography are extremely useful for diagnostic purpose. Chronic pancreatitis may induce local inflammatory complications (pseudocysts, chronic serosal effusions, fistulae) duodenal stenosis and segmental portal hypertension. A strict correlation of clinico-pathological findings is very important in the diagnostic procedure of chronic pancreatitis. Intraoperative diagnosis (either histologic, either cytologic) is of paramount importance in the diagnosis of a pancreatic mass. Histology is prominent in the definition of the specific form of pancreatitis.     

Anatomopathologic pictures of chronic pancreatitis

Morphology of pancreas (either esocrine, either endocrine) was studied in 29 cases of surgically treated chronic pancreatitis (27 cases of chronic calcifying pancreatitis and 2 cases of chronic obstructive pancreatitis). Parenchymal sclerosis in chronic calcifying pancreatitis (CCP) which represents the goal of our study was graded as mild (10 cases), moderate (10) and severe (7). Immunoperoxidase staining (PAP method) for insulin, glucagon, somatostatin, pancreatic polipeptide (PP), vasoactive intestinal polipeptide (VIP) and gastrin, was used to investigate endocrine pancreas. Acinar sclerosis and endocrine damage were closely related. Progression of sclerosis into islet appears to follow vascular pedicles producing a fragmentation into small cell groups as final result. In all cases of moderate or severe sclerosis, A/B cell ratio was increased due to the reduction of insulin positive cells. "Adenoma-like complexes", i.e., apparent concentration of islets, resulting from the loss of the acinar component, were observed in 7 cases with moderate or severe sclerosis. Nesidioblastosis was a prominent feature in all cases but one, with a positivity for insulin in 11 cases, for glucagon in 13, for somatostatin in 6 and for PP in 17. No positivity for gastrin was observed, while VIP was detected in a few ganglia. An increased amount of PP cells in islet and budding from the ducts was noticed and their presence outside the pancreatic head was demonstrable in 4 out of the 7 distal pancreatectomy specimens. Our data confirm the secondary involvement of the endocrine pancreas in the sclerotic acinar process.     

慢 性 胰 腺 炎 MR 诊断

目的探讨磁共振(MR)多种成像技术对慢性胰腺炎诊断的准确性及其临床应用价值。方法选择25例经手术病理、临床追踪和其他影像学方法证实的慢性胰腺炎MRI进行回顾性分析,其表现包括胰腺形态和体积改变、信号特征、动态增强扫描和MRCP所见。检查方法包括平扫冠状位T2WI,轴位T1WI,轴位T2WI,轴位T1WI FS(脂肪抑制)序列,磁共振胰胆管水成像(MRCP),动态增强前后的T1WI FS序列。结果胰腺体积弥漫性增大、T1WIFS病变区信号减低、动态增强扫描同步强化及串珠状扩张胰管穿透病变区是慢性胰腺炎的典型表现。结论MRI能更早发现慢性胰腺炎,显示胰管的改变和假性囊肿,对慢性胰腺炎诊断具有重要价值。     

The cytological spectrum of chronic pancreatitis

Chronic pancreatitis (CP) refers to a spectrum of changes generally seen after repeated injury that ranges histologically from mild fibrosis to extensive fibroinflammatory replacement of acinar tissue with accumulation of calcific debris. Because CP can share clinical and radiological features with malignancy, it often is sampled by fine-needle aspiration (FNA). The cytology files at Hennepin County Medical Center (HCMC) were searched for 20 consecutive cases of CP sampled by FNA. Clinical data and cytological findings were recorded. A spectrum of cytological findings typifies aspirates of CP. In most cases, mixed inflammation with debris and calcific material is present. Often, ductal cells are present and at most show mild atypia but generally appear organized. Often, fibrotic acinar tissue also is present while definitive islets are identified only rarely. Although these cytological findings were consistent with CP, 3 of 17 patients with follow-up were found to have pancreatic ductal adenocarcinoma.     

Current surgical treatment for chronic pancreatitis

Chronic pancreatitis (CP) is a painful, yet benign inflammatory process of the pancreas. Surgical management should be individualized because the pain is multifactorial and its mechanisms vary from patient to patient. Two main pathogenetic theories for the mechanisms of pain in CP have been proposed: the neurogenic theory and the theory of increased intraductal/intraparenchymal pressures. The latter theory is strongly supported by the good results of drainage procedures in the surgical management of CP. Other possible contributing factors include pancreatic ischemia; a centrally sensitized pain state; and the development of complications, such as pseudocysts and stenosis of the duodenum or common bile duct. Common indications for surgery include intractable pain, suspicion of neoplasm, and complications that cannot be resolved with radiological or endoscopic treatments. Operative procedures have been historically classified into 4 categories: decompression procedures for diseased and obstructed pancreatic ducts; resection procedures for the proximal, distal, or total pancreas; denervation procedures of the pancreas; and hybrid procedures. Pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy, once the standard operations for patients with CP, have been replaced by hybrid procedures, such as duodenum-preserving pancreatic head resection, the Frey procedure, and their variants. These procedures are safe and effective in providing long-term pain relief and in treating CP-related complications. Hybrid procedures should be the operations of choice for patients with CP.     

Major pancreatic resections for chronic pancreatitis

OBJECTIVE: Indications for major pancreatic resections have been expanded to include complicated chronic pancreatitis (CP). We assessed clinical findings and outcomes and evaluated histology in patients who had major pancreatic resections for CP. We also determined if histologic findings were associated with persistent postoperative pain. DESIGN: We reviewed charts and slides from 44 patients who underwent major pancreatic resections for CP between 1989 and 1999. RESULTS: The etiology for disease included alcohol (n = 15), hereditary (n = 5), idiopathic (n = 6), pancreas divisum (n = 3), stricture (n = 2), trauma (n = 2), systemic lupus erythematosus (n = 1), and unknown (n = 10). Patients included 20 men and 24 women; ages ranged from 22 to 76 years. Perioperative mortality and morbidity were 0% and 4.5%, respectively. Persistent pain was present in 25 (57%) of the 44 patients, and pain was encountered more frequently in patients with alcoholic pancreatitis (67%) versus other etiologies (52%), and in those who underwent Whipple/Beger or total resections (68%) versus distal or subtotal pancreatectomy (42%). Metaplastic changes were present in 14 cases, and ductal atypia was seen in 9 cases. No malignancies were found. Acinar necrosis and acute inflammation were seen more often in patients with persistent pain than in those who were pain free (P =.081). CONCLUSION: Major pancreatic resection for CP can be performed with low morbidity and mortality. This procedure relieves pain in nearly half the patients. There is a wide spectrum of histopathologic changes seen in CP, including ductal atypia and metaplastic changes. Acute exacerbations of CP identified histologically at the time of surgery and alcohol as etiology for CP may be associated more frequently with intractable pain.     

The endocrine pancreas in chronic pancreatitis

Summary The endocrine pancreatic tissue from patients with severe primary chronic pancreatitis (n=6), secondary chronic pancreatitis due to duct obstruction by carcinoma (n=6) and non-diabetic, non-pancreatitic controls (n=4) was studied qualitatively and quantitatively using specific immunocytochemistry and electron microscopy. Grouping of variously sized islets in the sclerotic tissue (sclerosis islets), islet neoformation by ductuloinsular proliferation, and intrainsular fibrosis were the main qualitative findings. Immunocytochemical quantitation of the distribution of insulin (B), glucagon (A), somatostatin (D) and pancreatic polypeptide (PP) producing cells revealed a significant relative increase in the number of A cells and a decrease in the number of B cells of the sclerosis islets in primary chronic pancreatitis (B-44.1±9.3%:A-38.3±2.4%:D-8.6±5.1%:PP-4.6±4.1%) as well as in secondary chronic pancreatitis (B-38.0±14.3%:A-38.4±19.0%:D-9.1±5.8%:PP-14.5±23.4%) compared with controls (B-71.1±8.1%:A-24.3±5.5%:D-8.0±2.8%:PP-0.5±0.4%). The number of PP cells was significantly increased in primary chronic pancreatitis only. It is suggested that scarring of the exocrine pancreas affects islet composition, probably by impairment of the local circulation and of glucose diffusion, thus leading to reduction of the number and glucose sensitivity of B cells. The hyperplasia of A and PP cells appears to be a secondary phenomenon due to the loss of B cells.     

The morphological basis for the evolution of acute pancreatitis into chronic pancreatitis

Conclusions There are many reasons to believe that the necrosis-fibrosis sequence is the basic pathogenetic event in the evolution of chronic pancreatitis. This sequence implies that acute pancreatitis, probably in its severe relapsing form, may be the cause of chronic pancreatitis. To make this concept relevant to the individual patient and the natural course of his/her disease, the extent and distribution pattern of necrosis in acute pancreatitis has to be carefully evaluated with regard to the restitutional processes (i.e. restitutio ad integrum, pseudocyst, intrapancreatic fibrosis) that may follow. Such an analysis reveals that only after severe acute pancreatitis and only under certain conditions, such as the occurrence of intrapancreatic necrosis involving the main duct, development of chronic pancreatitis can be anticipated. The individuality of each patient's pancreatitis demands a thorough clinical and morphological assessment of the pancreas in order to assign the appropriate therapy to this disease and halt its progression (Warshaw 1990).