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Biomedical subjects

H A Reber

Publications and source records attributed to H A Reber.

At least 73 records · Page 4Linked to original sources
PubMed1994

Emphysematous cholecystitis after ERCP.

Emphysematous cholecystitis is a rare variant of acute cholecystitis, most frequently seen in elderly, debilitated, or diabetic patients. This report documents the development of fulminant sepsis due to acalculous cholecystitis after endoscopic retrograde cholangiopancreatogram (ERCP) in an otherwise healthy patient with suspected malignant obstructive jaundice. Three other cases of acute cholecystitis have been reported in the literature after ERCP. Although not proven to prevent infectious complications during ERCP, strong consideration should be given to prophylactic antibiotics in patients with suspected malignant obstruction and/or coexistent medical illness, eg, diabetes. When attempts at decompression of the obstructed biliary system by endoscopy fail, decompression by percutaneous or surgical routes should be considered in a timely fashion.

Acute Disease↗
PubMed1994

Indications for surgery in severe acute pancreatitis.

The decision to operate on a patient with severe acute pancreatitis is often difficult and requires mature clinical judgment. Those indications that are widely accepted include: 1. For differential diagnosis, when the surgeon is concerned that the symptoms are the result of a disease other than pancreatitis for which operation is mandatory; 2. In persistent and severe biliary pancreatitis, when an obstructing gallstone that cannot be managed endoscopically is lodged at the ampulla of Vater; 3. In the presence of infected pancreatic necrosis; and 4. To drain a pancreatic abscess, if percutaneous drainage does not produce the desired result. Other indications that are less well defined and somewhat controversial are: 1. The presence of sterile pancreatic necrosis involving 50% or more of the pancreas; 2. When the pancreatitis persists in spite of maximal medical therapy; and 3. When the patient's condition deteriorates, often with the failure of one or more organ systems. For these latter three indications, guidelines have been presented that permit a logical approach to management, although uncertainty remains. Surgeons should strive to describe in precise terms the clinical state of their patients at the time that operation is performed, as well as the findings at and technical details of the surgery. This should allow further refinement in the management of this still vexing problem.

Abscess↗
PubMed1994

Sources of pancreatic pathogens in acute pancreatitis in cats.

The source(s) of pancreatic pathogens is uncertain, although the colon is usually implicated. We studied whether pathogens may spread from different sites in a feline model of the disease. Acute pancreatitis was induced using a standard technique and a distinctive clinical strain of Escherichia coli as the marker bacterium. E. coli were placed in the colon, gall bladder, main pancreatic duct, or obstructed renal pelvis of control cats (no pancreatitis) and acute pancreatitis cats. Pancreases were colonized from each source, whether or not pancreatitis was present. The pancreatic colonization rate was greater in acute pancreatitis only when E. coli had been placed in the colon. In conclusion, E. coli may spread to the pancreas from different sources. The high rate of pancreatic colonization in both control and inflamed glands suggested that, clinically, bacteria may spread to the pancreas more frequently than is currently thought.

Acute Disease↗
PubMed1994

Dopamine in models of alcoholic acute pancreatitis.

Acute oedematous pancreatitis and acute haemorrhagic pancreatitis were studied using the low pressure duct perfusion models of alcoholic pancreatitis in cats. After creating either form over 24 hours, each pancreas was histologically graded and assigned an inflammatory score (0-16; absent-severe). Urinary trypsinogen activation peptide concentrations were also used as a measure of severity. Using the model of acute haemorrhagic pancreatitis, it was previously shown that low dose dopamine (5 micrograms/kg.m) reduced the inflammatory score at 24 hours and that this effect was mediated by a reduction in pancreatic microvascular permeability acting via dopaminergic and beta adrenergic receptors. Further studies were conducted and are reported here. In experiment 1 different doses of dopamine in established alcoholic acute haemorrhagic pancreatitis were studied. In group 1 control cats (no dopamine), the inflammatory score was 10.5 (interquartile range (IQR)4). In groups 2, 3, and 4, haemorrhagic pancreatitis was induced. Twelve hours later dopamine was infused for six hours, in the doses of 2 micrograms/kg.min, 5 micrograms/kg.min, and 50 micrograms/kg.min respectively. The inflammatory score in group 2 was 7 (IQR 0.5, p < 0.05 v group 1), in group 3 it was 7 (IQR 2, p < 0.05 v group 1), and in group 4 it was 7 (IQR 4, p < 0.05 v group 1). This was matched by significantly lower levels of urinary tripsinogen activation peptide at 24 hours. In experiment 2 (group 5) we tried to reduce microvascular permeability further by combining dopamine with antihistamines, but there was no improvement in the inflammatory score. As oedematous pancreatitis is the commoner and milder form of acute pancreatitis in clinical practice, in experiment 3 we looked at the effect of dopamine in this model. In group 6 control cats (no treatment), the inflammatory score was 7 (IQR 3, p < 0.05 v group 1). In group 7 cats given dopamine (5 micrograms/kg.min for six hours) from 12 hours after the onset of actue oedematous pancreatitis, the inflammatory score was reduced to 4(IQR 2, p < 0.05 v group 6). This was matched by a significant reduction in the 24 hour urinary tripsin activation peptide concentration.

Acute Disease↗
PubMed1994

Routes of spread of pathogens into the pancreas in a feline model of acute pancreatitis.

The routes of spread of pathogens into the pancreas in acute pancreatitis were investigated. Four experiments were performed: (1) cats with and without acute pancreatitis were given 10(7) Escherichia coli (E coli) intravenously, (2) in cats with acute pancreatitis 10(8) E coli was placed in the colon. In half of them the colon was then enclosed in an impermeable bag to prevent transmural spread. (3) E coli (10(4)) was placed in the pancreatic duct in cats with and without acute pancreatitis. (4) In cats with acute pancreatitis 10(5) E coli was placed in the gall bladder. In half of them the common bile duct was ligated to prevent biliary-pancreatic reflux. After 24 hours, intravenous E coli infected the pancreas in six of nine cats with acute pancreatitis and three of 10 controls. After 72 hours E coli spread to the pancreas from the colon in six of nine cats with acute pancreatitis. This was prevented by enclosing the colon in an impermeable bag (p = 0.02). In five of six cats with acute pancreatitis and five of six controls E coli placed in the pancreatic duct colonised the pancreas within 24 hours. Pancreatic colonisation from the gall bladder occurred in five of six cats with a patent common bile duct and in three of six with an obstructed common bile duct. In conclusion, in cats E coli can spread to the pancreas by the blood stream, transmurally from the colon, and by reflux into the pancreatic duct.

Acute Disease↗
PubMed1994

Pancreatitis associated with adult choledochal cysts.

We reviewed the records of 32 adult patients with choledochal cysts (CDC) to determine the characteristics of the associated pancreatic disease. Eighteen patients (56%) had 30 documented episodes of pancreatitis with epigastric pain and elevated serum amylase levels. Three patients developed a prolonged course with a pancreatic phlegmon and one patient died secondary to a pancreatic abscess after endoscopic retrograde cholangiopancreatography (ERCP). Pancreatitis occurred in all types of CDC and was not related to the age, gender or race of the patient. There was an association with the size of the CDC: 90% of patients with CDC > or = 5 cm developed pancreatitis compared with only 9% of patients with CDC < 5 cm (p < 0.0004). In addition, ERCP was performed in 14 patients and demonstrated an abnormal pancreaticobiliary duct junction in eight (57%). All eight patients with an abnormal pancreaticobiliary junction developed pancreatitis compared with only 2 out of 6 patients with normal pancreatic duct anatomy (p < 0.006). Patients undergoing surgical bypass rather than resection also tended to have higher rates of pancreatitis (80 vs. 50%). One patient with a Type I CDC and chronic pancreatitis was treated with surgical resection of the CDC and pancreatic head; this combined procedure relieved the pain. Microscopic examination of the CDC and the abnormal "common channel" within the pancreas revealed identical fibrous thickening of the duct walls with focal chronic inflammation and loss of surface epithelium. In conclusion, these data stress the previously unrecognized high incidence of symptomatic pancreatic inflammatory disease that accompanies adult CDC.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Pancreatic interstitial pH regulation: effects of secretory stimulation.

BACKGROUND: Bicarbonate secretion by pancreatic ducts presumably releases an equivalent amount of acid into the parenchyma. The purpose of this study was to determine the effects of this acid load on pancreatic interstitial pH (pHI). In addition, we examined the relationship of pHI to changes in pancreatic blood flow (PBF), which may be important in acid disposal. METHODS: After validation of a microelectrode method for measurement of pHI in anesthetized cats, the effects of secretin (2 IU/kg intravenously) and cholecystokinin (0.08 microgram/kg intravenously) were examined. PBF was measured simultaneously by the H2 gas clearance technique. RESULTS: Secretory stimulation with secretin produced an increase in pancreatic bicarbonate secretion (146 +/- 23 microEq/15 minutes, p < 0.01). This secretion was associated with a fall in pHI from 7.36 +/- 0.02 to 7.31 +/- 0.02 (p < 0.001), which returned to baseline after 25 minutes. There was an accompanying increase in PBF from 118 +/- 32 to 148 +/- 35 ml/min/100 gm (p < 0.01). In contrast, stimulation with cholecystokinin only slightly increased pancreatic secretion (49 +/- 19 microliters/15 minutes) and had no significant effects on pH or blood flow. CONCLUSIONS: These results suggest that pancreatic secretion of bicarbonate, but not protein, releases H+ into the interstitium, an acid tide comparable to the alkaline tide during acid secretion by the stomach. This interstitial acidosis was accompanied by an increase in PBF. The increase in blood flow may be important in pH homeostasis, contributing to the disposal of this acid.

Animals↗
PubMed1994

Endoscopic measurement of pancreatic blood flow.

Based on the notion that reductions in pancreatic blood flow may play a role in the pathophysiology of chronic pancreatitis, a method for measuring pancreatic blood flow, using H2 gas clearance with a ductal electrode, was developed. Preliminary animal experiments using this methodology suggest that the fibrotic pancreas behaves like a closed compartment. The scarring results in ductal and interstitial hypertension, which decreases pancreatic blood flow. This reduction in blood flow may be important in both the pathogenesis of the disease as well as the etiology of the pain. Preliminary human studies, measuring pancreatic blood flow with an H2 electrode placed endoscopically, support these findings. Further studies will be necessary to confirm this novel hypothesis.

Animals↗
PubMed1993

Cost-benefit analysis of the work-up for pancreatic cancer.

We reviewed the records of 126 patients with pancreatic cancer to assess the value of diagnostic tests. The most commonly performed studies were computed tomography (CT) (97% of patients), endoscopic retrograde cholangiopancreatography (ERCP) (44%), and fine-needle aspiration (FNA) (41%). Of 34 patients who were found to have a mass in the body or tail of the pancreas on CT, 13 underwent ERCP; the results found by ERCP did not affect the management of the patients, whereas the results of FNA in 12 patients eliminated the need for operation. Of 14 patients with suspected metastases as evidenced by CT, the results of 3 ERCPs had no impact, whereas 5 of 7 patients who had FNAs avoided operation. Of five patients with normal results on CT, three had an ERCP that identified tumor. Of 26 patients with atypical CTs, the results of 12 of 16 ERCPs and 3 of 5 FNAs confirmed cancer. In contrast, in 48 patients with a mass in the head of the pancreas and biliary dilatation, ERCP did not alter the patients' management; only 3 of 14 patients who had FNAs avoided operation. Thus, the results of ERCP rarely altered the management of the patient when the CT showed a mass but was useful when the scan was normal or atypical. FNA was helpful in patients with cancer in the body or tail of the pancreas or with suspected metastases and in confirming the diagnosis when the CT was inconclusive.

Adenocarcinoma↗
PubMed1993

Assay of trypsinogen activation in the cat experimental model of acute pancreatitis.

An enzyme-linked immunosorbent assay for trypsinogen activation peptide (TAP) was used to measure urinary TAP levels in standard feline models of acute oedematous pancreatitis and acute haemorrhagic pancreatitis. It has been shown that the extent of pancreatic damage as assessed histologically is significantly greater in the model of acute haemorrhagic pancreatitis. This increase in damage has been found to be associated with a significantly greater increase in the excretion of urinary TAP.

Acute Disease↗
PubMed1993

Differential effects of experimentally induced chronic pancreatitis on neuropeptide immunoreactivities in the feline pancreas.

The distribution and concentration of calcitonin gene-related peptide (CGRP), substance P (SP), vasoactive intestinal polypeptide (VIP), neuropeptide Y (NPY), and gastrin-releasing peptide (GRP) immunoreactivities in the pancreas of cats with experimentally induced chronic pancreatitis and of age- and sex-matched controls were investigated. By narrowing the main pancreatic duct between the head and the body to approximately 25% of its normal diameter, we induced within 5 weeks chronic pancreatitis restricted to the body and tail. In control animals, peptide immunoreactive nerves were distributed to the islets, acini, and ducts; the latter were predominantly innervated by fibers immunoreactive for NPY, VIP, or CGRP. The vasculature received an abundant supply of NPY-, CGRP-, and, to a lesser extent, SP-containing axons. Within intrapancreatic ganglia, peptide immunoreactivities were identified in fibers and ganglion cells, with the exception of CGRP and SP immunostaining, which could be visualized only in fibers. In animals with chronic pancreatitis, the innervation pattern of each peptidergic system was comparable to that described in controls. However, there was a remarkable increase in the density and staining intensity of VIP and NPY immunoreactive fibers in the exocrine parenchyma and fibrous septa of the body and tail, where chronic pancreatitis developed. Fibers immunoreactive for CGRP and SP also were moderately denser than in controls, whereas those containing GRP immunoreactivity did not show any detectable changes. In addition, a marked increase of the immunostaining for VIP and, to a much lesser extent, for NPY and GRP, was observed in neurites supplying the head of the pancreas, which appeared devoid of histologically detectable pathological alterations. Radioimmunoassay analysis confirmed the immunohistochemical observations. The increased density of distinct peptidergic nerves in the pancreas with induced chronic pancreatitis might be the result of compensatory phenomena in response to the inflammatory process.

Animals↗
PubMed1993

Treatment of pancreatic carcinoma.

Pancreatic carcinoma remains a significant cause of cancer death worldwide. In spite of more effective diagnostic techniques, most patients still have advanced and incurable disease when the diagnosis is made. Treatments differ depending on the extent of the disease at presentation, but accurate staging preoperatively is difficult. The Whipple procedure is now done with an operative mortality of 5% or less. More effective means of nonoperative palliation are being developed. Adjuvant therapy is still largely ineffective.

Cause of Death↗
PubMed1993

Indications for surgery in necrotizing pancreatitis.

The decision to operate on a patient with severe acute pancreatitis is often difficult and requires mature clinical judgment. Indications that are widely accepted include to establish the differential diagnosis, when the surgeon is concerned that the symptoms are due to a disease other than pancreatitis for which an operation is mandatory; in persistent and severe biliary pancreatitis, when an obstructing gallstone is lodged in the ampulla of Vater and cannot be managed endoscopically; in the presence of infected pancreatic necrosis; and to drain a pancreatic abscess, if percutaneous drainage does not produce the desired result. Other indications that are less well defined and somewhat controversial are the presence of sterile pancreatic necrosis involving 50% or more of the pancreas, when the pancreatitis persists despite maximal medical therapy, and when a patient's condition deteriorates. For these last three indications, guidelines have been presented that permit a logical approach to management, although uncertainty remains. Surgeons should strive to describe in detail and precisely the clinical state of their patients at the time that an operation is done, as well as the findings and technical details of the operation. This should allow further refinement in the management of this vexing problem.

Diagnosis, Differential↗