[The fluorescein dilaurate serum test following metoclopramide and secretin stimulation for evaluating pancreatic function. Contribution to the diagnosis of chronic pancreatitis].
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Abstract:
A new method of exocrine pancreatic function testing is described. After oral administration of a standard meal containing fluorescein dilaurate (FDL) metoclopramide (10 mg) and secretin (1 U/kg) are given as intravenous bolus injection. The best discrimination between normal and abnormal pancreatic function was found to be the individual peak serum fluorescein concentration within 180 minutes. 184 patients were studied and divided into 4 groups according to the final diagnosis: group 1: 44 healthy controls; group 2: 87 patients with chronic pancreatitis; group 3: 21 patients with different pancreatic diseases; group 4: 32 patients with different gastrointestinal disorders. Sensitivity of the FDL serum-test in detecting chronic pancreatitis was 87%, specificity was 97%. Considering patients with different gastrointestinal disorders specificity dropped to 77%. FDL serum-test revealed superior as compared to the FDL urine test. Correlation between FDL serum-test and secretin ceruletide test was significant (r = 0.72, p less than 0.001).Keywords:
Secretin
Metoclopramide
Pancreatic function
Bolus (digestion)
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ABSTRACT Intravenous injection of 1.0 mg glucagon brings about a marked increase in the serum concentration of insulin in normal subjects. This increase sets in before the increase in blood sugar and reaches a peak 2–8 minutes after the injection. Intravenous injection of 75 units secretin also results in a rapid increase in the serum concentration of insulin in normal subjects. This increase is less marked than that following glucagon and reaches its peak 3–4 minutes after the injection. It must be assumed that glucagon as well as secretin contribute to the pronounced increase in insulin concentration during oral administration of glucose.
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The uptake of 75Se Selenomethionine by the pancreas has been evaluated in 102 patients and compared with the secretin-pancreozymin test of pancreatic function.In groups of patients with chronic pancreatitis and cancer of the pancreas abnormal scans closely parallel the diminished exocrine secretion, especially bicarbonate output, following a submaximal dose of secretin.Thirty per cent of the group with no pancreatic abnormality have abnormal scans, though the secretin- pancreozymin test is normal.Though a normal scan excludes the presence of chronic pancreatitis and cancer of the pancreas with a probability greater than 90%, an abnormal scan is found so frequently in normal subjects that it does not provide a reliable index of impaired pancreatic function.383 Reasonfor Omission No. of Cases Incomplete follow up 5 Gastro-jejunostomy 2 Incomplete record of data from secretin-pancreozymin test 1 1 Patient intolerant of gastroduodenal tube 3 Specimen lost or broken
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Abnormality
Pancreatic function
Bicarbonate
Pancreatic Disease
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The pancreozymin-secretin test was performed on 73 patients with chronic pancreatitis and on 34 with cancer of the pancreas. Duodenal contents were abnormal in 88% of the patients with chronic pancreatitis and in 94% with cancer of the pancreas. The most common abnormality among volume, concentration of bicarbonate, and amylase output of the duodenal contents was low amylase output. The present study strongly suggests that the addition of pancreozymin to the secretin test can detect a diminished enzyme secretory capacity of the pancreas better than can secretin alone. This test can also aid in the diagnosis of diseases of the biliary tract and in differentiating obstructive jaundice by observing changes in bile response of the duodenal contents and by microscopic examination of bile sediment.
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Abnormality
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Chronic alcoholic
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Pancreatic function
Exocrine pancreatic insufficiency
Chronic alcoholism
Billroth II
Exocrine pancreas
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In diabetic patients plasma levels of pancreatic polypeptide (PP) increased four fold after intramuscular injection of secretin (50CHRU, Eisai Co.) in spite of the lack of response of plasma insulin, plasma glucagon and blood glucose levels. In control subjects, PP levels did not change significantly after secretin injection. Since pancreatic polypeptide has is known to have an inhibitory effect on the exocrine pancreas, the present study suggests the possibility that disturbed function of the exocrine pancreas in diabetic patients could be related to the remarkable response of PP to secretin-stimulation.
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Gastric inhibitory polypeptide
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The diagnosis of chronic pancreatitis usually is based on imaging studies, pancreatic function tests, and the presence of characteristic clinical features. In Japan, diagnostic criteria for chronic pancreatitis were established in 1983 and revised in 1995. Under the new criteria, the secretin test (a duodenal intubation test) and the combination of nonivasive tests, N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) and fecal chymotrypsin (FCT), have been recommended for evaluating exocrine pancreatic function in patients with chronic pancreatitis. In the present study, the diagnostic value of these two noninvasive tests was compared to the secretin test. Although noninvasive tests are less sensitive and specific for determining exocrine pancreatic impairment than the secretin test, greater reliability for diagnosing chronic pancreatitis can be obtained by performing the BT-PABA and fecal chymotrypsin tests simultaneously. Combining BT-PABA and FCT is easy and useful and should be performed at least twice to obtain reliable results.
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Pancreatic function
Exocrine pancreatic insufficiency
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One hundred and thirty-nine patients were examined for possible chronic pancreatitis by means of both pancreozymin-secretin test and endoscopic pancreatography of pancreatocholangiography. Pancreatic function as assessed by the pancreozymin-secretin test was impaired in 89 (64%) of the entire group. No significant relationship was demonstrated between pancreatic secretion of fluid, bicarbonate and amylase and the diameter of main pancreatic duct in both the entire group of the subgroup of patients with pancreatic dysfunction. On pancreatogram no gross morphological abnormalities were found in a high proportion of patients whose pancreatic function was impaired in minimal to moderate degree. There was a significant linear correlation between the diameters of the main pancreatic duct and common bile duct. These data question the value of endoscopic pancreatography in the diagnosis of low to moderate grade chronic pancreatitis.
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Bicarbonate
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The clinical diagnosis of chronic pancreatitis is usually based on imaging studies, pancreatic function tests, and the presence of characteristic clinical features. In Japan, diagnostic criteria for chronic pancreatitis were established in 1995. The secretin test (a duodenal intubation test) and the combination of noninvasive tests, N-benzoyl-L-tyrosyl-p-aminobenzoic acid (BT-PABA) and fecal chymotrypsin (FCT), have been recommended for evaluating exocrine pancreatic function in patients with chronic pancreatitis. In the present study, the diagnostic value of these two noninvasive tests was compared to the secretin test. Although noninvasive tests are less sensitive and specific for determining exocrine pancreatic dysfunction than the secretin test, greater reliability for diagnosing chronic pancreatitis can be obtained by performing the BT-PABA and FCT simultaneously. Assessment of exocrine pancreatic function is important not only to diagnose chronic pancreatitis but also to decide a treatment method with pancreatic enzyme preparation.
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Pancreatic function
Exocrine pancreatic insufficiency
Exocrine pancreas
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A simple evocative test has been used to study pancreatic function. Serial estimations of amylase and lipase in blood serum are made at intervals up to six hours and again at 24 hours after injecting intravenously standard doses of secretin and pancreozymin. The results of 213 tests on a normal group, in pancreatic disease, in biliary and hepatic diseases have been analysed and compared with the results of duodenal intubation and an oral glucose tolerance test. A combined evocative test and oral glucose tolerance test provide evidence of pancreatic dysfunction in the majority of cases of cancer of the pancreas and chronic pancreatitis. The conditions of the test are described and the pathological lesions in which false positive evocative tests may be found are indicated. The simple evocative test provides the earliest biochemical evidence of pancreatic disease in some patients with cancer of the pancreas and chronic pancreatitis.
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To the Editor:—
Of the clinical varieties of chronic pancreatitis, that associated with alcoholism presents the most difficult problem in therapy. From the reported work one cannot conclude whether the alcohol exerts its effect by direct action on the duodenal mucosa or whether it acts by absorption into the blood stream and secondarily involves the pancreas. Lowenfels et al1demonstrated an increase in both the volume and amylase content of the pancreatic fluid after the intravenous injection of alcohol. Gizelt2believed the action of alcohol to be the summation of direct stimulation of the gland by the absorbed drug, direct stimulation of secretin in the duodenum, and an indirect stimulation of secretin secondary to alcohol induced acid production in the stomach. Dreiling et al3demonstrated that intravenous administration of alcohol neither stimulated the pancreas nor had a deleterious effect on patients with or without pancreatitis. Brooks andSecretin
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Pancreatic Disease
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