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The name juvenile tropical pancreatitis syndrome (JTPS) is proposed for a disease which affects young people of both sexes in certain parts of the tropics and which is characterised by abdominal pain, diabetes, steatorrhoea, and pancreatic calcification. The condition seems to start with blockage of the pancreatic ducts by laminated secretions or inspissated mucus plugs which later calcify. Chronic pancreatitis follows. The hypothesis is that plugs are the result of pancreatic stasis due to prolonged lack of food in the stomach and/or gastroenteritis and dehydration. Most plugs are probably dislodged during convalescence when protein-containing foods are eaten and stimulate vigorous flow of pancreatic juice. The sluggish pancreatic flow produced by very-low-protein diets may not dislodge plugs. Repeated infection and anorexia can enlarge the plugs which ultimately calcify. JTPS therefore occurs in Third-World areas with a high rate of childhood infections, and where low-protein staples are taken. Cereal staples seem to reduce the incidence of JTPS in endemic areas because of their protein content.
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PMID:Pathogenesis of juvenile tropical pancreatitis syndrome. 610 87

Chronic pancreatitis is a serious disease with high morbidity and high mortality. It mostly affects young adults and specifically people with long-term alcohol intake. The diagnosis must be suspected in patients with abdominal pain of unknown origin and in patients with diarrhoea and/or weight loss, particularly if they regularly use alcohol or present with a mild diabetes developed after the age of 30 years. Fundamental problems, such as the aetio-pathogenesis and the mechanism for the abdominal pain, are still unanswered. Contradictory observations concerning the natural history have been reported and further studies are needed to characterize the long-term course of symptoms and complications. The long-term management of patients requires careful attention to medical abuse and to complications (pseudocysts, duodenal ulcer, overt diabetes, and exocrine insufficiency). The high risk for malignant diseases also has to be taken into consideration.
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PMID:Chronic pancreatitis: pathogenesis, natural history and conservative treatment. 638 43

Forty five cases of chronic pancreatitis have been diagnosed between January 1966 to July 1983 in the Hospital A. Posadas. The diagnosis was confirmed by the presence of one or more of the following data: pancreatic calcifications positive in 35, abnormal secretin test 37, ultrasonography and computed tomography pathological findings 10. Surgical operations were carried out in 25 patients and biopsy taken in 5. Thirty nine (86.6%) were males, 6 (13.3%) females, the mean age in each group was 47.4 and 39.8 years. Chronic alcoholism was certain in 41 (91.9) patients, in the remainder 4 no other etiologic factors were found. The main clinical data were: Weight loss 38 (84.4%) diabetes 34 (75.5%) pain 33 (73.3% in 7 as acute pancreatitis) Steatorrhea 23 (51.1%) jaundice 16 (35.5%- 11 by extrahepatic biliary tree obstruction, 5 by hepatic cirrhosis) pseudocysts 12 (26.6%). The more common associated diseases were: hepatic cirrhosis 6, fatty liver 2 (17.7%) gastroduodenal ulcer 6 (13.3%) cancer 4 (8.8%--gastric 1, pancreatic 3). In order to study the frequency of the clinical data the patients were grouped according to the presence or absence of calcifications and the etiologic factor Symptoms and signs were matched and statistic analysis (coefficient association phi) was made. Only a moderate association between acute pancreatitis in no calcified group and diabetes in calcified group were found. The chronologic study of certains clinical data shows that acute pancreatitis, jaundice, pseudo-cyst and surgical operations were significative more frequent in the first five years while diabetes has little more frequency in the second five year period. Twenty six surgical operations were carried out in 25 patients; 20 (76.9%) due to complications, 6 (23.1%) secondary to pain (pancreatic resection 3, pancreatoyeyunostomy 2, exploration 1). Twenty three patients were lost to follow-up, 12 died and 10 are still alive. This last group was followed at regular period, 8 remained asymptomatic and 2 have intermittent abdominal pain related to alcoholic ingestion.
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PMID:[Chronic calcified pancreatitis. Our experience]. 639 6

The patient with diabetes represents to the surgeon a particular challenge in the management of acute abdominal problems. In addition to their ongoing and potential metabolic problems, diabetics have specific difficulty in their ability to handle infections and heal wounds. The present report reviews the general principles in the peri-operative management of diabetics and discusses the implications in the diabetic of several specific clinical problems. In view of the known accelerated atherosclerosis associated with diabetes, the risks of anesthesia and surgery must be assessed in the context of the coronary, cerebral, visceral, and peripheral vascular status. Infections in diabetics (potential or established) must be treated aggressively and promptly. Acidosis in the diabetic with abdominal pain must be considered both a metabolic problem and a possible secondary manifestation of an intra-abdominal process. In view of these challenges, the need for careful, anticipatory management of the diabetic patient facing major abdominal surgery is clear.
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PMID:Diabetes and abdominal surgery: the mutual risks. 642 50

The absence of ketoacidosis is thought to be characteristic of generalized lipoatrophic diabetes. It is widely believed that lipoatrophic diabetic patients are able to tolerate starvation and therapeutic insulin withdrawal, due to absence of subcutaneous body fat, the substrate essential for ketogenesis. In this article, we document nine episodes of acidosis and accelerated ketone body formation in a 24-yr-old woman whose deterioration followed episodes of dietary excesses without evidence of intercurrent infection or other identifiable forms of metabolic stress. Serum C-peptide measurements demonstrated that an absolute insulin deficiency did not exist. During short-term, experimental, dietary manipulations, excess dietary calories worsened the hyperglycemia and hyperlipidemia but did not reproduce the ketoacidotic state. Excess fat added to the diet was the most poorly tolerated of the food groups, causing ketonuria, hypertriglyceridemia, and abdominal pain. Our experience with this patient suggests that increased food consumption, insufficient insulin relative to an insulin-resistant state, and increased amounts of insulin counterregulatory hormones (stress), acted in concert to cause acidosis and increased ketone body formation.
Diabetes Care
PMID:Recurrent ketoacidosis in acquired, total lipodystrophy (lipoatrophic diabetes). 643 2

Severe abdominal pain was the major indication for operation in 85 patients with chronic pancreatitis. Preoperative endoscopic retrograde cholangiopancreatography (50 patients) or intraoperative pancreatic ductograms (44 patients) demonstrated dilated or obstructed major pancreatic ducts in 50 patients (59%), nonvisualization of the distal duct in 10 patients (12%), and normal or small sized ducts in 34 patients (40%). Operative procedures, tailored according to duct morphology, included pancreatic duct drainage (46 patients), subtotal (40% to 80%) pancreatectomy (21 patients), near-total (85% to 95%) pancreatectomy alone (eight patients), and near-total or total pancreatectomy and intrahepatic islet autotransplantation (10 patients). Pancreatic duct drainage resulted in pain relief in 37/46 patients (80%) followed for 6 years. However, 20/46 patients (43%) had continued loss of pancreatic function after duct drainage as measured by the development of insulin-dependent diabetes (16 patients) or steatorrhea (seven patients). Seven years after subtotal pancreatectomy, pain relief was partial in 9/21 patients (43%) and complete in five patients (24%). A higher incidence of hypoglycemic or ketoacidotic complications was noted in patients treated by subtotal pancreatectomy (three patients, 14%) than by duct drainage (one patient, 2%). Near-total pancreatectomy was the most effective surgical procedure in relieving pain, but late sequelae in three patients (38%) included one hypoglycemic death and two ketoacidotic episodes. Five years after near-total pancreatectomy and islet autotransplantation, one patient remained permanently insulin independent; three patients were insulin independent for 4, 5, and 15 months, respectively, but subsequently developed nonketosis-prone diabetes (tested by insulin withdrawal) and require 15 to 30 U of insulin daily; three patients had immediate insulin requirements and currently need 20 to 30 U of insulin per day but are nonketosis prone; and two patients are ketosis prone and require 30 to 60 U of insulin daily. Our analysis suggests that 5-year survival of patients undergoing operation for chronic pancreatitis is similar after treatment by duct drainage, subtotal pancreatectomy, or near-total pancreatectomy, regardless of duct morphology. Five years after duct drainage or subtotal pancreatic resection, a high incidence of diabetes (59% and 48%) and/or continued pain (20%) and (35%) can be expected.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Chronic pancreatitis: long-term surgical results of pancreatic duct drainage, pancreatic resection, and near-total pancreatectomy and islet autotransplantation. 643 70

A two year combined retrospective and prospective study of 555 acute medical admissions to a district general hospital was carried out to assess the value of emergency biochemical, haematological, radiological, and electrocardiographic tests in diagnosis and treatment. For the study the tests were considered helpful only if they disclosed an abnormality and resulted in a definite diagnosis or change of treatment which would not have been possible from the history and examination alone. A total of 2372 emergency tests were carried out in the 555 patients who presented with 579 acute medical problems. Only 403 (17%) of the test results were abnormal and, of these, only one third helped in treatment and less than one third helped in diagnosis. The most useful diagnostic tests were serum amylase activity in abdominal pain, the electrocardiogram in chest pain, the chest radiograph in respiratory problems, and cerebrospinal fluid analysis in suspected meningitis or subarachnoid haemorrhage. The most useful tests in treatment were blood sugar value in diabetes, PCO2 in obstructive airways disease, and haemoglobin concentration in gastrointestinal haemorrhage. Of the tests requested by far the most often--blood urea and serum electrolyte concentrations--only 7% gave abnormal results and were rarely of any help in either diagnosis or treatment. Analysis of the reasons for the uncritical use of emergency tests by house officers suggested that better undergraduate training, regular audit by senior members of medical units, abolition of routine investigational procedures, and more selective laboratory reports would help to build up the house officer's confidence in his own skills of history taking and physical examination without recourse to indiscriminate use of laboratory and other investigations.
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PMID:Do emergency tests help in the management of acute medical admissions? 643 48

The clinical and biochemical data obtained in 85 patients with diabetic ketoacidosis (DKA) are presented. DKA is an acute exacerbation of diabetes, a characteristic clinico-biochemical syndrome including increasing thirst, polyuria, adynamia, dryness of the skin and mucous membranes, anorexia, nausea, vomiting, occasionally abdominal pain, Kussmaul's breath, acetone odour in the exhaled air, circulatory collapse, prerenal azotemia, stupor, coma. Glycemia level exceeds 19 mmol/l, blood pH over 7.3. The disease is marked by neutrophilic leukocytosis, blood count shift to the left, elevated blood content of creatinine and urea. It was established that the degree of consciousness abnormality does not always correlate with the degree of the clinico-biochemical manifestations of DKA. During DKA, coma occurs relatively seldom (5.9%). It is suggested to use the term "diabetic ketoacidosis", incipient or marked, indicating the degree of consciousness abnormality (stupor, coma).
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PMID:[Diabetic ketoacidosis (causes, clinico-biochemical correlations and terminology problems)]. 644 Dec 97

Endoscopic retrograde cholangiopancreatography (ERCP) is generally regarded as a safe and useful investigation in the diagnosis and management of diseases of the pancreas and biliary tree. Asymptomatic hyperamylasemia is not uncommon following this procedure, but clinical pancreatitis is rare. The authors report on a 56-year-old man who suffered life-threatening acute hemorrhagic pancreatitis 2 weeks after ERCP was performed for the investigation of abdominal pain. He subsequently had insulin-dependent diabetes mellitus, which was not present at the time of ERCP.
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PMID:Acute hemorrhagic pancreatitis and diabetes mellitus following endoscopic retrograde cholangiopancreatography. 674 53

The 564 consultations performed by a general medicine consultation service during its first year were analyzed in order to provide a concrete definition of this new academic domain. Of the consultations, 52 percent were for patients on the surgical service. Among these patients, the most common reason for consultation was the preoperative management of chronic illness, specifically, hypertension, diabetes, and angina; 47 percent of such patients had two or more chronic illnesses. The service recommended cancellation of planned surgery in 2 percent and postponement in 9 percent of the 210 patients seen preoperatively. Patients on the psychiatric service accounted for 47 percent of the consultations. In this group, diagnostic issues were the most common reasons for consultation, that is, abdominal pain, dementia, and the suspicion of thyroid disease. Only 12 percent of the patients were seen for prognostic reasons, usually related to the planned use of electroconvulsive therapy or tricyclic antidepressants. The service was evaluated by the referring physicians who rated the service favorably on its "mechanics," as well as on its qualitative performance. However, complaints of triviality were voiced when the average length of the list of recommendations seemed disproportionate to the complexity of the problems. The service was also evaluated by the residents who had provided consultations. From their perspective, the service was more successful in teaching the "art" of consultation than the "science." This experience provides an operational definition of the work facing a general medicine consultation service as well as data useful in focusing future educational programs and research efforts.
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PMID:General medicine consultation. Lessons from a clinical service. 685 76


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