Cited 0 times in

45 0

Pancreozymin 및 secretin제재에 의한 췌장기능검사에 관한 연구

Other Titles
 Studies on pancreatic function test by means of stimulation with pancreozymin and secretin 
Authors
 최흥재 
Issue Date
1965
Description
의학과/박사
Abstract

[영문] The pancreatic function test based on the analysis of doudenal contents after stimulation of pancreas with pancreozymin and/or secretin has recently been widely adopted as the best available method of diagnosing chronic exocrine pancreatic disease. Secretin was discovered in 1902 by Bayliss and Starling, and the first attempt to establishe a pancreatic function test in man by stimulating the pancreas with secretin was made by Chiary et al. in 1926. In 1943 pancreozymin was first isolated from the small intestine by Harper and Raper. Duncan et al. were the first to perform a combined pancreozymin-secretin test in man. An examination of the value of pancreozymin-secretin test was prompted by the recent availability of a highly purified potent preparation of pancreozymin-cholecystokinin, "Cecekin" (Vitrum Co., Sweden), prepared by Jorpes and Mutt (1959). However, so far only limited information is available. The standardization of the method for the pancreozymin-secretin test has not well been established. Various investigators, using different preparetions of pancreozymin or secretin with variable potencies and purities, have employed different techniques which vary the dose of stimulants, duration of duodenal collection, parameters of pancreatic function or method of statistical analysis. Thus, further studies are required. The parameters of pancreatic function which were usually determined previously have been the volume of secretion and the maximal bicarbonate concentration. Recently, the diagnostic determination of the enzyme contents of duodenal juice has gained increasing significance since the pancreozymin-secretin test with potent pancreozymin preparation has been utilized. Among the three enzymes of amylase, lipase and trypsin, the most extensive data are concerned with measurements of amylase, while very scant information is available on trypsin measurements. This is in part due to the difficulties of accurate measurements of trypsin. In 1962 Grossman descibed the ethod of trypsin measurement utilizing p-toluene-sulfonyl-L-arginine methyl ester (TAME) as a substrate and a pH-stat automatic titrator. This method is simple and rapid as well as highly sensitive and reporducible. haverback et al. (1963) reported the diagnostic significance of fecal tryptic activity as measured by this method, but there is no single report on the application of this method in the pancreozymin-secretin test. The present study was undertaken to determine the value of trypsin measurements by this method as well as that of other parameters in duodenal-pancreatic juice obtained in the course of performing the pancreozymin-secretin test. Methods Pancreatic function tests by means of pancreozymin and secretin have been performed on 76 patients since the author started trypsin determinations of duodenal juice using TAME as a substrate and a pH-stat automatic titrator. "Vitrum" preparations of secretin and "Cecekin" (pancreozymin-cholecystokinin) were used in this study. The patients fasted for 12 hours and 10 mg. of chlortrimeton was given intramuscularly one hour before the test to prevent a sensitivity reaction to secretin and pancreozymin. The Wallace-Diamond double-lumened gastroduodenal tube was introduced under fluoroscopic observation and the tip placed at the ligament of Treitz, so that the proximal tube openings were in the antrum of the stomach and the distal openings in the third portion of the duodenum. Simultaneous aspiration with an electric Gomco suction pump was maintained through each tube and gastric juice were collected separately. After collection of a 20-minute basal sample of duodenal contents, 75 Ivy units of Cecekin were slowly injected intravenously, and a 10-minute post-Cecekin aspirate was collected. Then Vitrum secretin, in a dose of 1 clinical unit per kg. of body weight was give by intravenous injection and the aspirate was collected for an additional 60-minute. This consisted of two 10-minute samples followed by two 20-minute samples. These specimens were collected in iceimmersed test tubes until the tests were completed. The volume of the individual collection of duodenal aspirate was measured. The bicarbonate concentration was estimated, measssuring the CO^^2 combining power by the method of Van Slyke. The concentration of trypsin was determined by Haverback's modification of Grossman's method, of amylase by the modification of Somogyi saccharogenic method, and of lypase by the method of Cherry and Crandall. The outputs of bicarbonate and enzymes were obtained from the product of the concentration and volume of the sample. Subjects and Results Seventy-six patients were divided into 5 groups: control, chronic exocrine pancreatic disease, postgastrectomy, biliary disease and a miscellaneous group. The maximal concentration of bicarbonate and enzymes represents the highest value obtained in any of the specimens in each patient. The volume of flow and output of bicarbonate were calculated as the total amount secreted in 60 minutes after secretin injection, while the outputs of the enzymes as the total amount secreted in 70 minutes after pancreozymin. All of the output data were also expressed in terms of body weight. The frequency distribution curve of the data for volume and bicarbonate was farily symmetrical, hence arithmetic means were used. However, because of the skewed distribution of the data for enzymes, their data were transformed to logarithms and geometric means were calculated for statistical analysis. 1. Control group The control group was comprised of 20 patients without any clinical or laboratory evidence of pancreatic, hepatobiliary disease, or malabsorption. The mean, standard deviation, coefficient of variation and lower limits of normal were calculated. The lower limit of normal (calculated as the mean minus two standard deviations) for the volume was 67ml./60min. (1.1ml/kg.); for bicarbonate, the maximal concentration 65.4 mEq./L., and output 3.9 mEq./6omin. (0.06mEq./kg.); of trypsin, maximal concentration 21.1mg.%, output 26.4ng./70min. (0.45mg./kg.); of amylase, maximal concentration 40,200 u.%, output 62,400 u./70 min. (990 u.Kg.); of lypase, maximal concentration 145 u./ml., output 1,875 u./70 min. (32.6 u./kg.). The data for all parameters did not vary appreciably from Sun's study (1963). (He did not make trypsin determinations.) 2. Chronic pancreatic disease group This group includes seven patients with proven chronic pancreatitis and three patients with confirmed carcinoma of the pancreas. In chronic pancreatitits the means of all parameters were significantly lower than those of the control group (p<0.001) except for the mean of volume which less significantly diminished (p<0.05). The volume of flow showed no diagnostic significance in chronic pancreatitis as almost all patients had "normal" results. In one patient without steatorrhea the data for all parameters were normal apart from the maximal concentration of trypsin and lipase which were abnormally low. Of the remaining 6 patients abnormal values were observed for the output of trypsin and amyalse and for the maximal concentration of bicarbonate in all patients. In three patients with carcinoma of pancreas the means of all parameters, especially amylase, trypsin and bicarbonate were markedly decreased as compared with those of the control group and even the group of chronic pancreatitis. In all 3 carcinoma patients all the data for bicarbonate and enzymes were far below the normal limits. The data for volume were abnormal in 2 of 3 patients. A reduction in the volume of duodenal contents as well as in bicarbonate and enzymes may well be characteristic of patients of this type, the reduced volume is probably due to obstruction of the ducts. This is in contrast to the findings in the patients with chronic pancreatitis in which the volume usually remains at "low normal" levels. Trypsin was the only parameter which showed abnormal values in all of 10 patients with chronic pancreatic disease, and seemed to have the best diagnostic value, followed by bicarbonate and amylase in that order. 3. Postgastrectomy group Malabsorption after gastric resection is frequently encountered, especially after Billorth Ⅱ precedures. This has been attributed to a reduced gastric reservoir, intestinal hurry, inadequate absorptive capacity of intestine, improper mixing or destruction of pancreatic enzymes, defective stimulation of pancreatic secretion and of gallbladder emptying, decreased sensitivity of the pancreas to secretin and pancreozymin, or inadequate pancreatic secretion. In the present study which includes 7 patients who had total or subtotal gastrectomy 1 to 12 years previously, the means of most parameters were only slightly lower than that of the control group, with no appreciable difference between the patients with or without symptoms such as diarrhea or weight loss. It is difficult to compare data in postgastrectomy patients with normals because of the difficulty of gastroduodenal intubation. In one of 7 postgastrectomy patients the values for all parameters were below normal. This patient may also have had pancreatic insufficiency although its relationship to the gastric resection is not known. 4. Biliary disease group Thirty patients with disease of the biliary tract were studied by means of pancreozymin-secretin test. This group was further divided into 2 groups; postcholecystectomy group and cholecystitis group. In the group of 10 patients who had cholecystectomy previously, the means of the trypsin data were much decrease, while the means of volume, bicarbonate, amylase and lipase were similar to those of the control group. The cholecystitis group (20 patients) showed values similar to those of the control group or between those of control and postgastrectomy group. Agren (1936) reported in gallbladder disease a significant rise in the volume of duodenal output folowing secretin. The present study showed only a slight increase in mean volume in the cholecystectomy group, but a moderate decrease in the cholecystitis group. It was remarkable that the data for one or more enzymes were abnormal in 13 of 30 patients with biliary disease. 5. Miscellaneous group This group was composed of 9 patients with malabsorption or diarrhea from various disease such as sprue, regional ileitis or ulcerative colitis which were not classifiable into group 1 to 4. The results were completely normal in 6 patients, but abnormal in 3 patients. Trypsin data were abormal in all 3 patients, and bicarbonate, amylase and lipase data were abnormal in 2 respectively. The secretin test has been described to be of value in the differential diagnosis of steatorrhea. The possibility of secondary protein deficiency or associated pancreatic disease being the cause of pancreatic insufficiency in these diseases has been suggested in the literature. The present studies on pancreatic function test by means of stimulation with pancreozymin and secretin in 76 patients proved the following facts: this test is valuable in the diagnosis of pancreatic insufficiency; trypsin measurement is the most sensitive parameter of pancreatic function, followed by bicarbonate and amylase. The pancreatic function test based on the analysis of doudenal contents after stimulation of pancreas with pancreozymin and/or secretin has recently been widely adopted as the best available method of diagnosing chronic exocrine pancreatic disease. Secretin was discovered in 1902 by Bayliss and Starling, and the first attempt to establishe a pancreatic function test in man by stimulating the pancreas with secretin was made by Chiary et al. in 1926. In 1943 pancreozymin was first isolated from the small intestine by Harper and Raper. Duncan et al. were the first to perform a combined pancreozymin-secretin test in man. An examination of the value of pancreozymin-secretin test was prompted by the recent availability of a highly purified potent preparation of pancreozymin-cholecystokinin, "Cecekin" (Vitrum Co., Sweden), prepared by Jorpes and Mutt (1959). However, so far only limited information is available. The standardization of the method for the pancreozymin-secretin test has not well been established. Various investigators, using different reparetions of pancreozymin or secretin with variable potencies and purities, have employed different techniques which vary the dose of stimulants, duration of duodenal collection, parameters of pancreatic function or method of statistical analysis. Thus, further studies are required. The parameters of pancreatic function which were usually determined previously have been the volume of secretion and the maximal bicarbonate concentration. Recently, the diagnostic determination of the enzyme contents of duodenal juice has gained increasing significance since the pancreozymin-secretin test with potent pancreozymin preparation has been utilized. Among the three enzymes of amylase, lipase and trypsin, the most extensive data are concerned with measurements of amylase, while very scant information is available on trypsin measurements. This is in part due to the difficulties of accurate measurements of trypsin. In 1962 Grossman descibed the ethod of trypsin measurement utilizing p-toluene-sulfonyl-L-arginine methyl ester (TAME) as a substrate and a pH-stat automatic titrator. This method is simple and rapid as well as highly sensitive and reporducible. haverback et al. (1963) reported the diagnostic significance of fecal tryptic activity as measured by this method, but there is no single report on the application of this method in the pancreozymin-secretin test. The present study was undertaken to determine the value of trypsin measurements by this method as well as that of other parameters in duodenal-pancreatic juice obtained in the course of performing the pancreozymin-secretin test. Methods Pancreatic function tests by means of pancreozymin and secretin have been performed on 76 patients since the author started trypsin determinations of duodenal juice using TAME as a substrate and a pH-stat automatic titrator. "Vitrum" preparations of secretin and "Cecekin" (pancreozymin-cholecystokinin) were used in this study. The patients fasted for 12 hours and 10 mg. of chlortrimeton was given intramuscularly one hour before the test to prevent a sensitivity reaction to secretin and pancreozymin. The Wallace-Diamond double-lumened gastroduodenal tube was introduced under fluoroscopic observation and the tip placed at the ligament of Treitz, so that the proximal tube openings were in the antrum of the stomach and the distal openings in the third portion of the duodenum. Simultaneous aspiration with an electric Gomco suction pump was maintained through each tube and gastric juice were collected separately. After collection of a 20-minute basal sample of duodenal contents, 75 Ivy units of Cecekin were slowly injected intravenously, and a 10-minute post-Cecekin aspirate was collected. Then Vitrum secretin, in a dose of 1 clinical unit per kg. of body weight was give by intravenous injection and the aspirate was collected for an additional 60-minute. This consisted of two 10-minute samples followed by two 20-minute samples. These specimens were collected in iceimmersed test tubes until the tests were completed. The volume of the individual collection of duodenal aspirate was measured. The bicarbonate concentration was estimated, measssuring the CO^^2 combining power by the method of Van Slyke. The concentration of trypsin was determined by Haverback's modification of Grossman's method, of amylase by the modification of Somogyi Saccharogenic method, and of lypase by the method of Cherry and Crandall. The outputs of bicarbonate and enzymes were obtained from the product of the concentration and volume of the sample. Subjects and Results Seventy-six patients were divided into 5 groups: control, chronic exocrine pancreatic disease, postgastrectomy, biliary disease and a miscellaneous group. The maximal concentration of bicarbonate and enzymes represents the highest value obtained in any of the specimens in each patient. The volume of flow and output of bicarbonate were calculated as the total amount secreted in 60 minutes after secretin injection, while the outputs of the enzymes as the total amount secreted in 70 minutes after pancreozymin. All of the output data were also expressed in terms of body weight. The frequency distribution curve of the data for volume and bicarbonate was farily symmetrical, hence arithmetic means were used. However, because of the skewed distribution of the data for enzymes, their data were transformed to logarithms and geometric means were calculated for statistical analysis. 1. Control group The control group was comprised of 20 patients without any clinical or laboratory evidence of pancreatic, hepatobiliary disease, or malabsorption. The mean, standard deviation, coefficient of variation and lower limits of normal were calculated. The lower limit of normal (calculated as the mean minus two standard deviations) for the volume was 67ml./60min. (1.1ml/kg.); for bicarbonate, the maximal concentration 65.4 mEq./L., and output 3.9 Eq./6omin. (0.06mEq./kg.); of trypsin, maximal concentration 21.1mg.%, output 26.4ng./70min. (0.45mg./kg.); of amylase, maximal concentration 40,200 u.%, output 62,400 u./70 min. (990 u.Kg.); of lypase, maximal concentration 145 u./ml., output 1,875 u./70 min. (32.6 u./kg.). the data for all parameters did not vary appreciably from Sun's study (1963). (He did not make trypsin determinations.) 2. Chronic pancreatic disease group This group includes seven patients with proven chronic pancreatitis and three patients with confirmed carcinoma of the pancreas. In chronic pancreatitits the means of all parameters were significantly lower than those of the control group (p<0.001) except for the mean of volume which less significantly diminished (p<0.05). The volume of flow showed no diagnostic significance in chronic pancreatitis as almost all patients had "normal" results. In one patient without steatorrhea the data for all parameters were normal apart from the maximal concentration of trypsin and lipase which were abnormally low. Of the remaining 6 patients abnormal values were observed for the output of trypsin and amyalse and for the maximal concentration of bicarbonate in all patients. In three patients with carcinoma of pancreas the means of all parameters, especially amylase, trypsin and bicarbonate were markedly decreased as compared with those of the control group and even the group of chronic pancreatitis. In all 3 carcinoma patients all the data for bicarbonate and enzymes were far below the normal limits. The data for volume were abnormal in 2 of 3 patients. A reduction in the volume of duodenal contents as well as in bicarbonate and enzymes may well be characteristic of patients of this type, the reduced volume is probably due to obstruction of the ducts. This is in contrast to the findings in the patients with chronic pancreatitis in which the volume usually remains at "low normal" levels. Trypsin was the only parameter which showed abnormal values in all of 10 patients with chronic pancreatic disease, and seemed to have the best diagnostic value, followed by bicarbonate and amylase in that order. 3. Postgastrectomy group Malabsorption after gastric resection is frequently encountered, especially after Billorth Ⅱ precedures. This has been attributed to a reduced gastric reservoir, intestinal hurry, inadequate absorptive capacity of intestine, improper mixing or destruction of pancreatic enzymes, defective stimulation of pancreatic secretion and of gallbladder emptying, decreased sensitivity of the pancreas to secretin and pancreozymin, or inadequate pancreatic secretion. In the present study which includes 7 patients who had total or subtotal gastrectomy 1 to 12 years previously, the means of most parameters were only slightly lower than that of the control group, with no appreciable difference between the patients with or without symptoms such as diarrhea or weight loss. It is difficult to compare data in postgastrectomy patients with normals because of the difficulty of gastroduodenal intubation. In one of 7 postgastrectomy patients the values for all parameters were below normal. This patient may also have had pancreatic insufficiency although its relationship to the gastric resection is not known. 4. Biliary disease group Thirty patients with disease of the biliary tract were studied by means of pancreozymin-secretin test. This group was further divided into 2 groups; postcholecystectomy group and cholecystitis group. In the group of 10 patients who had cholecystectomy previously, the means of the trypsin data were much decrease, while the means of volume, bicarbonate, amylase and lipase were similar to those of the control group. The cholecystitis group (20 patients) showed values similar to those of the control group or between those of control and postgastrectomy group. Agren (1936) reported in gallbladder disease a significant rise in the volume of duodenal output folowing secretin. The present study showed only a slight increase in mean volume in the cholecystectomy group, but a moderate decrease in the cholecystitis group. It was remarkable that the data for one or more enzymes were abnormal in 13 of 30 patients with biliary disease. 5. Miscellaneous group This group was composed of 9 patients with malabsorption or diarrhea from various disease such as sprue, regional ileitis or ulcerative colitis which were not classifiable into group 1 to 4. The results were completely normal in 6 patients, but abnormal in 3 patients. Trypsin data were abormal in all 3 patients, and bicarbonate, amylase and lipase data were abnormal in 2 respectively. The secretin test has been described to be of value in the differential diagnosis of steatorrhea. The possibility of secondary protein deficiency or associated pancreatic disease being the cause of pancreatic insufficiency in these diseases has been suggested in the literature. The present studies on pancreatic function test by means of stimulation with pancreozymin and secretin in 76 patients proved the following facts: this test is valuable in the diagnosis of pancreatic insufficiency; trypsin measurement is the most sensitive parameter of pancreatic function, followed by bicarbonate and amylase.
URI
http://ir.ymlib.yonsei.ac.kr/handle/22282913/117276
Appears in Collections:
2. 학위논문 > 1. College of Medicine (의과대학) > 박사
사서에게 알리기
  feedback
Fulltext
교내이용자 서비스로 제공됩니다.
Export
RIS (EndNote)
XLS (Excel)
XML

qrcode

Items in DSpace are protected by copyright, with all rights reserved, unless otherwise indicated.

Browse