Acute necrotizing pancreatitis. Hypoperfusion may not be synonymous with gangrene.
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Contrast Media↗
Biomedical subjects
J M Howard
Publications and source records attributed to J M Howard.
Chylous ascites. A late complication of massive peripancreatic necrosis.
A 43-yr-old female underwent a normal endoscopic retrograde cholangiopancreatography (ERCP) because of ill-defined abdominal discomfort. A life-threatening pancreatitis with massive peripancreatic necrosis ensued, necessitating multiple necrosectomies. A colonic fistula required a temporary colostomy. Thirty-three months after onset of pancreatitis, although seemingly stable, she developed a massive chylous ascites, the fluid of which had a lipid content of approx 8000 mg%. Her serum cholesterol and triglyceride levels remained normal. During her third postpancreatitis year, while under observation and without operative intervention, the ascites began to clear slowly, almost completely clearing over the ensuing 16 mo. No comparable syndrome has been detected in a literature review, although eight patients with chylous ascites, possibly associated with pancreatitis, were identified. Since the senior author, in a career in pancreatic surgery, had not previously encountered the problem and since its natural history in this patient revealed spontaneous improvement, its description seems worthwhile.
Chylous Ascites↗
Pancreatojejunostomy: leakage is a preventable complication of the Whipple resection.
BACKGROUND: Leakage of the pancreaticojejunal anastomosis has been a major complication after pancreaticoduodenectomy (Whipple operation), frequently reported in an incidence of 5 percent to 15 percent. The most widely used techniques of anastomosis have been variations of end-to-end pancreaticojejunostomy. Complicating 152 end-to-end anastomoses, done by me (including 98 for carcinoma of the pancreas or ampulla), were 5 pancreatic anastomotic leaks; the fifth patient died of this complication. STUDY DESIGN: The death resulting from a pancreatic anastomotic fistula led me to change my technique to an end of the pancreas to side of the jejunum, mucosa-to-mucosa, pancreaticojejunostomy (intubated), a modification of the technique described by Cattell and used since 1985 by me in 56 consecutive patients. Patients were monitored for clinical evidence of a pancreatic fistula, including evaluation of amylase content in serum and, in most, in peritoneal drainage. Pancreatography through the exteriorized pancreatic catheter was possible if deemed advisable. RESULTS: No pancreatic duct was too small or pancreas too soft to permit effective anastomosis. No clinical evidence developed of a pancreatic fistula, "sentinel bleed," or acute pancreatitis, and no patient was recognized to have a high amylase content in the peripancreatic peritoneal drainage. Results of the pancreatogram were negative in three patients with peripancreatic infections and in one with severe cholestasis. CONCLUSIONS: Although consensus among surgeons does not exist as to technique of pancreatic anastomosis, the end-to-side, mucosa-to-mucosa pancreaticojejunostomy, intubated, has proved safer in my experience than end-to-end pancreaticojejunostomy. The experience has led me to believe that the technique may reduce the incidence of this fistula and contribute to making pancreaticojejunal leakage a preventable complication.
Anastomosis, Surgical↗
Adenocarcinoma of duodenum and ampulla of Vater: clinicopathology study and expression of p53, c-neu, TGF-alpha, CEA, and EMA.
Oncogenes, tumor suppressor genes, and growth factors are being explored as to their role in the initiation and progression of most neoplasms, but little information exists on the expression of oncoproteins or growth factors in adenocarcinoma of the duodenum or ampulla of Vater. This report covers expressions of p53, c-neu, TGF-alpha, CEA, and EMA in duodenal adenocarcinoma and ampullary adenocarcinoma, as well as correlations between expressions and tumor stage, histological grade and patient survival. The expression of p53, c-neu, TGF-alpha, CEA, and EMA has been studied in 15 duodenal adenocarcinomas and in eight ampullary adenocarcinomas by avidin-biotin-peroxidase complex indirect immunoperoxidase technique. The positive reaction for p53, c-neu, TGF-alpha, CEA, and EMA in duodenal adenocarcinoma was 20%, 60%, 60%, 73%, and 100%, respectively, and in ampullary adenocarcinoma, 13%, 100%, 50%, 63%, and 100%. Among the duodenal tumors, C-neu and p53 expression was noted more frequently in groups with high histological grades. Patients with c-neu positive duodenal adenocarcinoma had a shorter survival than the patients with c-neu negative duodenal adenocarcinoma (P < 0.01). C-neu product may serve as an unfavorable prognostic indicator in duodenal adenocarcinoma. No statistically significant correlation was found between the expressions of CEA, EMA, p53, and TGF-alpha and patient survival, tumor stage, or histological grade in either duodenal or ampullary adenocarcinomas.
Adenocarcinoma↗
Metastatic pancreatic neuroendocrine carcinoma causing Cushing's syndrome. ACTH secretion by metastases 3 years after resection of nonfunctioning primary cancer.
CONCLUSION: Following resection of a nonfunctioning neuroendocrine carcinoma of the pancreas, subsequent metastases, in the absence of a primary cancer (resected), developed the capacity to secrete ACTH and create the Cushing syndrome. BACKGROUND: Although neuroendocrine carcinomas of the pancreas may produce one or more hormones and may switch secretion to a different hormone, no report is identified of a metastasis, in the absence of the primary tumor, developing de novo the capacity to secrete ACTH. METHODS: A nonfunctioning islet cell carcinoma was resected and immunochemically stained for multiple hormones. Three years later hepatic metastases were partially resected and stained as before. RESULTS: The primary cancer stained negative for ACTH and cortisol, positive for serotonin, and focally positive for gastrin. Three years later, after the development of a florid Cushing syndrome, the metastasis stained strongly for ACTH and negative for serotonin.
Adrenocorticotropic Hormone↗
Pancreatitis associated with neuroendocrine (islet cell) tumors of the pancreas.
BACKGROUND: The association of pancreatitis with neuroendocrine tumors of the pancreas is uncommon, whereas its association with exocrine pancreatic cancer is well recognized. Since the latter, but not the islet cell tumor, is thought to originate within the ductal system, it is not surprising that pancreatitis is less likely to result from the islet cell tumor. The senior author has recently noted that the first recognizable indication of an islet cell carcinoma may be one or more discrete attacks of acute pancreatitis. METHODS AND RESULTS: Acute pancreatitis, resulting from an islet cell tumor, has been observed in five patients, in one of whom it had become chronic. In four of the patients, the tumor was malignant. A review of the English language literature reveals 14 such patients with pancreatitis, and 2 others have been noted in other languages (a total of 21 patients). The tumor was malignant in 15 of the 21 patients (71%). Although the development of pancreatitis was found to result from the obstruction of the duct in most patients, at least three seemed unrelated. In 12 of 21 cases (57%), an acute attack of pancreatitis, usually recurrent, was the initial syndrome, in contradistinction to pancreatitis resulting from exocrine tumors, which has usually been chronic in nature. CONCLUSION: Pancreatitis, particularly acute pancreatitis, may result from an islet cell tumor. Although unusual, its occurrence may be the first signal of the presence of the tumor. In our experience, obstruction of the pancreatic duct by the islet cell carcinoma appears to be the important etiologic factor.
Acute Disease↗
Hormone replacement therapy and cobalamin status in elderly women.
Serum cobalamin concentrations are frequently low in the elderly but the cause is often not apparent. Because oral contraceptives have been associated with low cobalamin concentrations in young women, we compared hormone use with cobalamin status in elderly women to determine whether it could account for their unexplained low cobalamin concentrations. Thirty-eight of the 111 women had abnormal cobalamin status (defined by low cobalamin, elevated methylmalonic acid, and/or elevated homocysteine concentrations) and 73 had normal status. There was no difference in hormone use between the two groups: 7 (18.4%) of the 38 cobalamin-deficient subjects used estrogens compared with 20 (27.4%) of the 73 control subjects. No differences in hormone use were apparent either when analysis was confined to abnormal serum cobalamin concentrations alone. Similarly, the 27 women taking hormones and the 84 women not taking hormones did not have significantly different serum cobalamin or serum total homocysteine concentrations. Indeed, hormone users had slightly, though not significantly, higher cobalamin concentrations and lower homocysteine concentrations than nonusers; furthermore, hormone users also had significantly lower serum methylmalonic acid concentrations. Thus, neither cobalamin concentrations nor cobalamin metabolic status were significantly worse in elderly women taking estrogen than in those not taking it (and, if anything, may have been slightly better). Hormone use does not appear to be a significant contributor to the low cobalamin concentrations or the mild metabolic evidence of cobalamin deficiency so often seen in the elderly.
Aged↗
Glucagonoma associated with calculous pancreatitis.
A Patient with a glucagonoma associated with calculous pancreatitis is reported. The authors know of only one other such patient. Because the calculous pancreatitis developed both upstream and downstream from the tumor, it cannot be attributed to obstruction of the pancreatic duct by the tumor. Continued critical appraisal is needed to determine whether the association of the glucagonoma and pancreatitis is etiologically related or merely coincidental.
Acute Disease↗
Observations on the developmental patterns and the consequences of pancreatic exocrine adenocarcinoma. Findings of 154 autopsies.
OBJECTIVE: To improve our future care of the patient with exocrine pancreatic cancer by seeking, within the limitations of our present approaches, additional information on the growth and spread of the cancer and its influences on the patient. DESIGN: Consecutive autopsies of all patients with exocrine pancreatic cancer were reviewed retrospectively by two surgeons and three pathologists. SETTINGS: Three teaching hospitals of the Medical College of Ohio, Toledo. MATERIALS: One hundred fifty-four consecutive autopsies of patients with exocrine pancreatic cancer during the period between 1952 and 1992. RESULTS: Intrapancreatic metastases or multicentric cancers were found in 12 patients. In 32 patients, pancreatic cancer skipped the lymph nodes, primarily draining the respective areas of the pancreas to metastasize to the secondary chain of nodes. In 13 patients, pulmonary metastases occurred without hepatic metastasis. Intrapancreatic contiguous extension was identified in 34 patients. Carcinoma of the body and/or tail of the pancreas was characterized by transperitoneal as well as hematogenous dissemination to a greater extent than was carcinoma of the head of the pancreas. Seven of 11 small tumors (< 2 cm in diameter) were associated with remote metastases. Relatively severe chronic obstructive pancreatitis was found to have resulted from pancreatic carcinoma in 18 cases, whereas in seven patients, pancreatic carcinoma probably developed in preexisting chronic pancreatitis. Thromboembolic disease was found in 30 patients, more frequently in the patients with the mucin-producing tumors of the pancreatic body and tail. In 21 patients, the amount of ascites was not proportional to the severity of peritoneal dissemination, vessel invasion, or recognizable hepatic dysfunction. Thromboembolic disease, severe infection, stress ulcer, and acute hemorrhagic erosive gastroenteritis were frequent systemic complications contributing to death. Malnutrition in the form of cachexia was undoubtedly a major, even dominant, feature in many patients that could not be quantitated from this data. CONCLUSIONS: Metastasizing cells frequently bypass the initial filters in lymph nodes, liver, or lung to become established in secondary or tertiary sites. Intrapancreatic metastases or multicentric tumors also may develop more frequently than generally has been recognized. Small cancers (< 2 cm in diameter) are often associated at autopsy with remote metastases. These facts would appear to limit the usefulness of the current staging of resected cancers of the pancreas. Cancers of the body or tail are characterized by transperitoneal and hematogenous spread to a greater extent than are those of the head. Anatomical studies often do not explain the cause or the extent of ascites associated with pancreatic adenocarcinoma. As previously indicated, chronic pancreatitis appears to be further confirmed as a precursor of pancreatic cancer.
Adenocarcinoma↗
Von Recklinghausen's disease associated with duodenal somatostatinoma: contrast of duodenal versus pancreatic somatostatinomas.
A case of Von Recklinghausen's disease with duodenal somatostatinoma is reported. A search of the world's literature revealed 27 patients with Von Recklinghausen's disease associated with an immunohistologically proved duodenal somatostatinoma. Twenty-nine cases of duodenal somatostatinoma not associated with Von Recklinghausen's disease and 32 cases of pancreatic somatostatinomas have been identified for comparison. While their histology may be similar in many respects, the duodenal and pancreatic somatostatinomas show significant differences, especially in hormonal and growth behaviors. In contrast to its pancreatic counterpart, the duodenal somatostatinoma is frequently associated with Von Recklinghausen's disease, is seldom associated with a recognizable "somatostatin syndrome," often contains psammoma bodies, and is less frequently associated with demonstrable metastases at the time of operation.
Adult↗
Overexpression of HER2/neu oncogene in pancreatic cancer correlates with shortened survival.
For the purpose of determining the prognostic significance of HER2/neu oncogene in pancreatic and ampullary cancers, 21 pancreatic cancers of ductal origin and six cancers of the ampulla of Vater were studied immunohistochemically using the monoclonal antibody (MAb) CB11, specifically reactive with HER2/neu product. Staining of the epithelium of the normal duct and acini was negative or weakly positive. Moderately and strongly positive reactions indicated the overexpression of this gene, and were found in 10 of 21 (47.6%) pancreatic cancers of ductal origin and in 2 of 6 (33.3%) ampullary adenocarcinomas. Overexpression of HER2/neu was closely and inversely related to the survival of the patients with pancreatic cancer of ductal origin: 19.1 +/- 11.7 mo for those not overexpressing vs 7.3 +/- 3.8 mo for the overexpressors (p < 0.01). Among the pancreatic cancer group, 11 patients underwent cancer resection. The average survival for the 7 with nonoverexpressing cancer was 21.4 +/- 14.3 mo vs 10.5 +/- 3.6 mo for those with overexpressing tumor. Among those not undergoing resection, the average survival for the 4 with nonoverexpressing cancer was 15.0 +/- 3.8 mo as contrasted to 5.2 +/- 2.1 mo for the overexpressors (p < 0.01). Although the number of patients is small, these findings suggest that the overexpression of HER2/neu gene product may be frequently found in pancreatic cancer of ductal origin and may be one of the useful prognostic biomarkers for this cancer.
Adenocarcinoma↗
Malignant islet cell tumor associated with hypercalcemia.
BACKGROUND: Three cases of islet cell tumors of the pancreas with hypercalcemia were studied, and 16 similar cases have been found in a 25-year review of the English-language literature. The purpose of the study was to review the cause of the hypercalcemia and the clinical characteristics of the tumors. METHODS: Tumor tissue retrieved from paraffin-embedded blocks was studied immunohistochemically for both parathyroid hormone (PTH) and PTH-related protein (PTHrP). PTH was measured in the serum in each patient and the serum PTHrP was measured by immunoassay in one patient. RESULTS: One of our patients had a fatal serum calcium level of 26.4 mg/dl. PTHrP stains were positive in two of our tumors, and one patient had an elevated PTHrP serum level. Serum PTH levels were normal or low in each patient. All three tumors were malignant and extremely vascular. The total group of 19 patients have in common hypercalcemia associated with a normal or low serum PTH level. Although the cause of hypercalcemia has not been proved, the tumors apparently produce PTHrP, because seven of eight tumors stained positive for PTHrP and each of the four patients tested had an elevated PTHrP serum titer. The tumors are extremely vascular, are usually malignant (17 of 18), and become large, but they are compatible with a relatively long patient survival time. CONCLUSIONS: These neuroendocrine tumors associated with hypercalcemia share several characteristics, but a claim that they represent another type of "functioning islet cell tumor" should await a clearer delineation of the cause of the hypercalcemia.
Adenoma, Islet Cell↗
Papillary cystic and solid tumors of the pancreas: a pancreatic embryonic tumor? Studies of three cases and cumulative review of the world's literature.
BACKGROUND: The papillary cystic and solid tumor of the pancreas is rare. It occurs predominantly in young women, and most present a benign behavior. The pathogenesis of this tumor has attracted a number of investigations but remains unclear. METHODS: We present three patients with this tumor and a review of 289 others from the world's literature, a total of 292 cases. On the basis of the analyses of the clinical and pathologic features from the reported cases, the pathogenesis of this unusual tumor has been further explored. RESULTS: Ninety percent of the patients were female, with a mean age of 23.9 years. The tumors were usually quite large with a mean diameter of 10.3 cm. Ninety-two percent of these tumors were totally or partially cystic. Rupture of the capsule resulted in hemoperitoneum in eight cases, five of which were without any identifiable cause. Forty-three tumors (14.7%) have been recognized as malignant. The overall prognosis has been excellent and an aggressive approach to resection is indicated. CONCLUSIONS: The results of immunohistochemical staining and electromicroscopy were rather diverse, but most, including the current cases, support the hypothesis that the tumor originates from pleuripotential embryonic stem cells. Thus the term pancreatic embryonic tumors seems preferable to papillary cystic and solid tumor of the pancreas to delineate the origin of the tumor and to reflect some of its biologic characteristics.
Adolescent↗
B-cell lymphoma of ampulla of Vater: observation for six years.
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Ampulla of Vater↗
Carcinoma of the ampulla of Vater and mesenteric fibromatosis (desmoid tumor) associated with Gardner's syndrome: problems in management.
To date, 29 patients with Gardner's syndrome have been identified who developed carcinoma of the ampulla of Vater, and many others have been identified with mesenteric fibromatosis (desmoid tumor), but there have been only four cases of Gardner's syndrome with both ampullary carcinoma and mesenteric fibromatosis reported in the world literature. This article focuses on the complications and major problems in management resulting from the simultaneous occurrence of these two known features of Gardner's syndrome: carcinoma of the ampulla of Vater and fibromatosis (desmoid tumor) of the intestinal mesentery.
Adolescent↗
The aftermath of HMO insolvency: considerations for providers.
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Bankruptcy↗
Gut permeability measured by polyethylene glycol absorption in abnormal gut fermentation as compared with food intolerance.
Gut permeability has been studied in patients with either food intolerance or abnormal gut fermentation as well as in normal subjects. Permeability was measured by polyethylene glycol absorption, and the reasons for this choice of probe are discussed. Results show that both symptomatic groups have statistically very highly significant deviations from the normal (P < 0.01), consisting of over-adsorption, significant at molecular weights 242, 286, 330 and 374. Whilst both study groups were different from the normal they were not different from each other. The implications for these findings in the diagnosis and management of food intolerance and abnormal gut fermentation are discussed.
Fermentation↗
Pancreatic cancer. Cytologic study of peritoneal washings.
OBJECTIVE: To delineate the frequency and significance of free cancer cells in the peritoneal cavity of patients with pancreatic exocrine adenocarcinoma. DESIGN: Randomly selected patients with pancreatic cancer had peritoneal washings performed at the beginning and conclusion of laparotomy. Results of cytologic studies were correlated with the clinical findings, size, spread, and resectability of the tumor and with the survival time of the patient. All patients were followed up until the present or until their deaths. SETTING: Tertiary care, referral hospitals in Toledo, Ohio. PATIENTS: Only patients with biopsy-proven adenocarcinoma of the pancreas were included. Thirty-six patients, yielding 62 specimens for cytologic study, were included. INTERVENTION: Peritoneal washings were performed at the beginning and completion of laparotomy. Each washing was evaluated independently by two skilled cytologists. If present, ascites was quantitated and studied cytologically. Biopsy specimens were obtained in each patient at the time of the study. MAIN OUTCOME MEASUREMENTS: Presence or absence of malignant cells in peritoneal fluid; maximal diameter, grade, and spread of cancer; presence and volume of ascitic fluid; resectability of cancer; and length of survival of the patient. RESULT: Of the 36 patients studied, three had positive cytologic findings. All three had peritoneal carcinomatosis. Of 11 patients with ascites, only one had positive cytologic findings. CONCLUSIONS: Results of cytologic studies of peritoneal washings or of ascitic fluid are seldom positive with pancreatic exocrine carcinoma. When positive, they denote a very grave prognosis.
Adenocarcinoma↗