BACKGROUND:Obesity increases the risk for severe acute pancreatitis, although abdominal obesity may be a better prognostic marker.AIM:To determine if a single anthropometric parameter best predicts severe acute pancreatitis and correlates with intra-abdominal fat.METHODS:Ninety-nine patients with acute pancreatitis were studied prospectively. Anthropometry included body mass index (BMI) and girths (umbilical/minimum waist, iliac/trochanter hip, thigh). Several waist-to-hip/waist-to-thigh ratios (WHR/WTR) were constructed. A CT-scan with calculation of cross-sectional abdominal fat areas was obtained in 37 cases.RESULTS:Severe acute pancreatitis occurred in 25 patients. Waist circumference (WC), WHR and WTR - all using the umbilical reference - most accurately predicted severe acute pancreatitis. Only umbilical WC was retained in multivariate analysis: the risk for severe acute pancreatitis increased 16% with every 1 cm (OR 1.16, 95%CI: 1.1-1.3). Abdominal obesity caused a 6-fold increase in risk. Umbilical WC correlated best with subcutaneous fat area (r = 0.791, P < 0.001), whereas WHR with intra-abdominal (r = 0.594, P < 0.001).CONCLUSIONS:Abdominal obesity according to umbilical WC is a better predictor for development of severe acute pancreatitis than BMI, minimum WC, WHR and WTR. The protocol for anthropometry must be standardized as it may affect results. Both subcutaneous and intra-abdominal fat appears to affect the likelihood of a severe outcome.

Background: Electrocardiographic abnormalities may be associated with acute pancreatitis (AP). Goals: To describe the electrocardiographic disturbances present in patients with AP and to assess differences in electrolyte and pancreatic enzyme levels among patients with and without these abnormalities. Study: Fifty-one consecutive patients with AP and without preexisting heart disease underwent a standard 12-lead electrocardiogram (EKG) and a serum electrolyte profile. EKG abnormalities were summarized in terms of frequencies, means, and standard deviations. Electrolyte and enzyme levels were summarized as medians. Differences were analyzed using the Mann-Whitney U test. Results: Twenty-eight patients (55%) had an abnormal EKG. Nonspecific changes of repolarization (20%), sinus tachycardia (12%), and left anterior hemiblock (10%) were the most frequent disturbances. Patients with sinus tachycardia had lower levels of phosphorus (2.3 vs. 3.4 mEq/L, P < 0.004) and calcium (8.4 vs. 9.1 mg/dL, P < 0.02). A tendency to higher levels of potassium and lower levels of phosphorus was found in patients with sinus tachycardia and nonspecific changes of repolarization, respectively. No differences were found in amylase, pancreatic amylase, or lipase among patients with normal and abnormal EKG. Conclusions: More than 50% of the patients with AP had EKG abnormalities, and these changes could be related to electrolyte alterations.

Chronic unexplained hypertransaminasemia is an isolated clinical manifestation of celiac disease (CD) and lacks of a clear physiopathological explanation. Since CD and tropical sprue (TS) have similar intestinal functional and histological pattern of injury and that an increased inflammatory response has been reported to occur in patients with irritable bowel syndrome (IBS), liver involvement might be expected to occur either in TS or IBS. However, according to author's prior observations, the frequency of hypertransaminasemia is significantly higher in CD than in TS and IBS-diarrhea predominant patients (IBS-D). Thus, based on current knowledge, intestinal mucosal damage, increased intestinal permeability and/or an active intestinal inflammatory response do not completely explain liver damage in CD. We hypothesize that other factors, unique to CD not present in TS or IBS-D, like gluten toxicity and the presence of tissular transglutaminase (tTG) an auto-antigen with pro-inflammatory and remodeling properties, act in addition to intestinal mucosal injury and account to hypertransaminasemia in CD. Further research focusing on the mechanisms of gluten and tTG hepatic toxicity, and/or the characterization of the expression, secretion and enteral-hepatic transport of certain pro-inflammatory cytokines is needed, to understand the possible links between intestinal and liver disorders seen in CD.

Pancreatic carcinoma may express Angiotensin (Ang) II receptors. Recently, the LAIIGS has been recognized in several human tissues. The Ang type 1 receptor (AT1) promotes cell proliferation, whereas the Ang type 2 receptor (AT2) has an opposite effect. Experimental blockade of AT1 decreases cellular proliferation in several tumors. Aim: Identify LAIIGS in the pancreatic cancer cell line Capan-1 and evaluate its role in cell proliferation and growth factors secretion. Methods: Ang I generation was measured in Capan-1 cells homogenate and culture media by RIA. Ang II was determined by immunocytochemistry (ICC) in Capan-1 cells. The presence of AT1 and AT2 was searched in cells by RT-PCR and ICC. The effect of Ang II and Losartan (AT1 blocker) on cell proliferation was analyzed by [3H] thymidine incorporation. Vascular endothelial growth factor (VEGF) and fibroblast growth factor 2 (FGF-2) were measured by ELISA in cell culture supernatants, before and after Ang II exposure. Results: Capan-1 cells homogenate generated Ang I (0.400 ± 0.079 ng/mL/h [Mean ± SD]) but Ang I was not found in the culture media. ICC demonstrated strong Ang II-immunoreactivity in Capan-1 cells. Capan-1 cells did not express AT1 or AT2, according to RT-PCR and ICC. Exogenous Ang II or Losartan did not modify cell proliferation. The Ang II treatment did not change VEGF secretion. The FGF-2 was non- detectable before and after Ang II treatment. Conclusions: The high Ang I generation and detection of Ang II in Capan-1 cells demonstrate the presence and functionality of a LAIIGS, which can play a role in the high cell proliferation and aggressive nature of pancreatic cancer. The absence of typical membrane-bound receptors (AT1 and AT2) to Ang II, and the lack of response to exogenous Ang II or Losartan suggests that LAIIGS operates in an intracrine manner and independently of circulating reninangiotensin system.

Complex interactions between acquired and genetic factors are involved in the natural history of CP. Tobacco might act as a disease modifier rather than as a direct or independent causal factor of CP. Aim: To analyze the role of smoking in the age of onset and diagnosis of alcoholic (ACP) and idiopathic (ICP) CP. Methods: CP patients (n=101) with known cigarette smoking habits were analyzed in 2 stages: 1) All patients were grouped as smokers or non-smokers and compared their age of onset and diagnosis of CP by using Student’s t test. The association between smoking intensity (number of packages/year) and age of onset and diagnosis of CP in the smokers was explored by using Pearson’s r index. 2)The same analysis was performed stratifying the 101 patients according to their etiology (ACP and ICP) and smoking habits. Results: The onset and diagnosis of CP in the whole group occurred at older age in smokers than in non-smokers (table). A direct significant (p<0.05) relationship between smoking intensity and age of onset and diagnosis of CP was found in all smoking cases (n=68, onset age r= 0.66, diagnosis r=0.64) as well as in both etiological subgroups (ACP onset age r=0.60, diagnosis r=0.56 and ICP onset age r=0.79 and diagnosis r=0.82).TABLEConclusions: Cigarette smoking delays the onset of clinical manifestations and age of diagnosis of CP mainly in idiopathic cases. This effect seems to be directly related to the smoking intensity.

Background: Pancreatic insufficiency may appear secondary to several intestinal disorders. It may contribute to malabsorption in tropical sprue (TS). Methods: The exocrine pancreatic function was evaluated with the indirect pancreolauryl test (PT) in 56 patients with TS. The PT results were analyzed and correlated with serum albumin levels, degree of intestinal atrophy, and steatorrhea. Results: Abnormally low values were found in 36 (64.2%) cases. A significant relationship was not observed between PT and hypoalbuminemia. Patients with more severe damage by intestinal biopsy tended to have lower PT values. No relationship was found between pancreatic insufficiency and steatorrhea (expressed as g/24 h), but patients with pancreatic insufficiency had increased stool fat concentrations (expressed as percentage of wet stool weight). All patients responded favorably to treatment with folic acid and tetracycline. Fifteen patients with abnormal initial PT values underwent a repeat PT after a 6-week therapy; all of them showed normalization of PT values. Conclusions: The abnormal exocrine pancreatic function found with an indirect test in patients with TS is probably secondary to a low pancreatic hormonal stimulation due to intestinal damage, as occurs in celiac sprue. These abnormalities are reversible after specific treatment for TS.

Background. CA 19-9 is used for diagnosis of gastrointestinal neoplasia, mainly pancreatic and biliary cancer. False positive results have been described in cholestasis. Objective. To establish the clinical value of CA 19-9 in the diagnosis of pancreatic and biliary cancer in patients with and without cholestasis. Methods. Five hundred forty-eight medical records of patients with serum CA 19-9 determination performed from May-1996 to June-1998 were reviewed. Cases were grouped by final diagnosis; malignancy was established by histology or clinical and radiological characteristics. ROC curves were used to calculate ideal cut-off values (ICV) for the test, Cholestasis was defined as bilirrubinemia above 3 mg/dL. Results. Thirty percent of serum determinations were done in patients with non-pancreatic and non-hepatobiliary benign diseases (only 1.3% with values greater than or equal to 100U/mL). CA 19-9 levels were higher in pancreatic and hepatobiliary malignancy compared to benign diseases of the same origin, as well as in pancreatic cancer when compared with hepatobiliary cancer. ICV for differentiation of malignant hepatobiliary diseases was set around 100 U/mL, with increased specificity when compared with the usual cut-off value (37 U/mL). Cholestasis increased the values of the antigen in malignant and benign diseases and modified the efficacy of the test by increasing sensitivity while decreasing specificity. The ICV for deter mining resectability in pancreatic tumors was 224 U/mL. Conclusions. CA 19-9 is a valuable test for diagnosis of malignant pancreato-hepatobiliary disease. Given that cholestasis modifies the operational characteristics of the test, a cut-off value has to be tailored for each patient depending on the clinical setting, so to maintain the usefulness of the marker.

Mery, Carlos M MD1; Carmona-Sánchez, Ramón MD1; Suazo-Barahona, Jorge MD1; León, Sergio Ponce-de MD2; Robles-Díaz, Guillermo MD1 Author Information

Descrito desde hace mas de 2, 000 anos, el esprue tropical (ET) continua siendo uno de los mayores enigmas en la medicina. Fue hasta mediados del siglo XX cuando esta enfermedad fue caracterizada como una entidad diferente a la enfermedad celiaca (enteropatia por gluten) y tratada con sulfonamidas y acido folico. El ET se encuentra distribuido mundialmente de manera irregular y en parches, siendo endemico en algunas areas tropicales de Asia (especialmente en la India), el Caribe (Puerto Rico, Cuba, Haiti y Republica Dominicana), Africa, la region norte de America del Sur y el Medio Oriente

Early detection of severe acute pancreatitis could represent a formidable task for the clinician with limited resources. We have previously proposed a series of parameters that can identify patients with severe acute pancreatitis. The aim of this prospective study was to compare Ranson criteria with those previously described by the authors (INNSZ criteria) in 78 patients with acute pancreatitis. Sensitivity, specificity, positive and negative predictive values and accuracy were similar in both scores. We found a good correlation (r = 0.65, p < 0.001) and agreement (z = 5.0, Kappa 0.69, p < 0.001) between Ranson and INNSZ criteria. Our results allow us to propose INNSZ severity criteria as an easy and inexpensive alternative in the evaluation of patients with acute pancreatitis.

The International Agency for Research on Cancer (IARC) of the WHO has recognized a cause-effect relationship between Helicobacter pylori (Hp) infection and gastric cancer of such magnitude that the presence of this infection increases the risk of gastric cancer approximately four times. Gastric cancer is currently the second cause of mortality due to malignant neoplasms in Mexico City. This article explores the association between Hp infection and gastric cancer incidence through an epidemiological study including 109 gastric cancer patients and 177 hospital controls in Mexico City. The study estimates that, in the population studied, Hp infection was present in 87.2% of the cases, compared with 82.5% of the controls. The odds ratio of having gastric cancer if infected with Hp was 1.44 IC95% 0.7-2.8. In addition, it was calculated that with eradication of Hp infection in the general population, gastric cancer incidence would decrease by at least 26.6%. An improvement of the actual sanitary conditions along with the development of an effective vaccine for Hp infection and the existence of increasingly effective treatments to eradicate the bacteria are the necessary next step for populational prevention and control of gastric cancer.

Normal absorption and digestion occurs in sequential stages. In the lumen of the proximal intestine pancreatic enzymes and bile salts transform complex substances in simple products which can be absorbed by the enterocyte and transported by lymphatics or portal veins. Malabsorption syndromes can be secondary to alterations in both digestion and/or absorption process. We herein review the tests used to establish the diagnosis of intestinal malabsorption syndromes with special reference to those available in our country. Finally we propose an algorithm taking into account the frequency of diseases causing malabsorption in Mexico.

At Instituto Nacional de la Nutrición SZ in Mexico City, we reviewed 30 years of experience and selected 46 patients with Pancreatic Diabetes (PD), without family history of Diabetes Mellitus (DM) with at less two years of follow-up. Alcoholic chronic pancreatitis (CP) was found in 36 patients, in seven it was idiophatic and in three was secondary to pancreatectomy. We compared the evolution of this patients with a group of (DM) patients similar in age, sex, glucemic control and time of onset. There were no statistical differences between groups in the follow-up of diabetic complications, only it was found a tendency to have higher lipid levels, macroangiopathy and retinopathy in those with DM. We concluded that CP have similar evolution as DM and could have deleterous complications in the large follow up.