Methods of Examination. Pain, dyspepsia, jaundice, general weakness and wasting are the main complaints of patients with diseases of the pancreas.

Inquiry

Pain, dyspepsia, jaundice, general weakness and wasting are the main complaints of patients with diseases of the pancreas.

Pain may vary in intensity and character. Attacks of paroxysmal pain, like in biliary colic, arising 3-4 hours after meals (especially after taking fatty food) are characteristic of calcareous pancreatitis. Pain is usually localized in the epigastrium or left hypochondrium to radiate into the back. Pain is sometimes so severe that can only be removed by spasmolytics or even narcotics.

Pain is especially severe in acute pancreatitis. It develops suddenly and persists for a few hours or days and even weeks. The pain is usually localiz­ed in the upper abdomen and is often girdling in character. Severe pain and its vigorous onset in acute pancreatitis are explained by a sudden obstruc­tion of the main pancreatic duct as a result of spasm and inflammatory oedema with subsequent sharp increase in pressure in small pancreatic duc-tules and irritation of the solar plexus.

Pain is very severe and prolonged in tumours of the pancreas. If the head of the pancreas is affected, pain is localized in the right hypochon-

drium and radiates into the back. If the tumour extends onto the body and tail of the pancreas, pain is felt in the entire epigastrium, left hypochon­drium, and its character may be girdling. Pain is intensified when the pa­tient is in the recumbent position because the tumour presses on the solar plexus. The patient would therefore assume a forced (half-bent) posture to lessen the pain. Boring pain is characteristic of chronic pancreatitis, although this form of the disease may be attended by severe pain as well.

Nausea and vomiting more frequently attend acute pancreatitis and are of reflex character. Chronic pancreatitis and tumour of the pancreas are characterized by dyspepsia which is due to upset enzymatic activity of the pancreas. Patients with chronic pancreatitis often complain of poor ap­petite, aversion to fatty foods, nausea, meteorism, diarrhoea with ample li­quid lustrous (fatty) and fetid faeces. Upset intestinal digestion causes rapid cachexia and general weakness.

Cancer of the head of the pancreas is characterized by the following symptoms '.jaundice is of the obstructive type, progressive; the skin is dark-brown (with a greenish hue); there are severe itching, and haemorrhages. The tumour presses the terminal portion of the common bile duct to obstruct bile outflow. Jaundice may develop in sclerosis of the head of the pancreas as well. This is the result of chronic pancreatitis.

Anamnesis. It is necessary to pay attention to certain factors that may stimulate the development of inflammatory diseases of the pancreas. Abuse of alcohol and fatty food, as well as a long-standing cholecystitis are among the predisposing factors.

Physical Examination

INSPECTION

The general inspection of the patient may reveal general cachexia and jaundice with skin scratches and haemorrhages into the skin that attend cancer of the pancreas. Acute pancreatitis is characterized by pallidness of the skin with cyanotic areas which appear as a result of respiratory and cir­culatory disorders developing in grave toxicosis. In long-standing chronic pancreatitis, in connection with digestive disorders, the patient may develop cachexia; his skin is dry and turgor decreases. Inspection may, in rare cases, reveal distension of the upper abdomen (cysts of the pancreas). Acute pancreatitis may be attended by abdominal flatulence.

Percussion over the pancreas can reveal dulled tympany or complete dullness in cases with considerable enlargement of the pancreas (in the presence of cysts or tumours).

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Chapter 7. Digestive System

PALPATION

Surface palpation of the abdomen of a patient with acute pancreatitis reveals tenderness and strain of the prelum muscles in the epigastrium, sometimes in the left hypochondrium or over the pancreas (Korte symp­tom).

Palpation of the pancreas is very difficult because of the deep position and soft consistency of the gland. Normal pancreas can only be palpated in 4—5 per cent of women and 1-2 per cent of men affected by cachexia with relaxed prelum and ptosis of the internal organs. The pancreas is only palpable when enlarged considerably. Consolidated pancreas affected by cirrhosis, newgrowth, or cyst can be easier palpated.

The pancreas should be palpated in the morning, after giving purgatives (with the empty stomach). The greater curvature should first be palpated; then the position of the pylorus should be determined and the right knee of the transverse colon palpated. The horizontal portion of the duodenum should preferably be outlined by palpation in order to find the point where the head of the pancreas might be better palpated. The head of the pan­creas is easier to palpate than its body or tail because of its greater size and frequent consolidation. Palpation is deep and sliding, usually above the right part of the greater curvature of the stomach. The Obraztsov-Strazhesko rule should be followed during palpation. The palpating hand is placed horizontally, 2-3 cm above the preliminarily found lower border of the stomach. The skin is pulled upwards and then the palpating hand presses gradually into the abdominal cavity with each expiration. As soon as the posterior wall is reached, the hand should slide in the downward direction.

A normal pancreas is a soft transverse cylinder, 1.5—3 cm in diameter.
The organ is immobile and painless. In the presence of chronic pancreatitis
and tumour of the pancreas, it can sometimes be palpated as a firm, ir­
regular, and slightly tender band. Conclusions should be derived very
carefully, because part of the stomach, the transverse colon, a pack of
lymph nodes and some other formations can easily be mistaken for the
pancreas.,,

Laboratory and Instrumental Methods

LABORATORY STUDIES

Coprological studies. Upset exocrine function of the pancreas has its ef­fect mainly on assimilation of food (mainly fats and proteins). Faeces become ample and of pasty consistency. Their colour is greyish; the smell is

rancid. Microscopic study of faeces reveals considerable amount of neutral fat and muscular fibres with preserved striated pattern. These coprological changes are revealed in cases with pronounced disorders in secretion of the pancreatic juice which occur, for example, in pancreatic duct obstructed by a stone or a tumour. Moderate pancreatic dysfunction can be compensated for by intestinal digestion and the action of microbial enzymes.

Insufficient digestion of food can be due to other causes. Then, in order to assess the pancreatic function, it is necessary to use methods by which the composition of the pancreatic juice can be studied directly, or the con­dition of the pancreas should be assessed by the blood and urine enzyme content. " Spontaneous" pancreatic juice, or juice liberated in response to special stimulation should be used for these studies. The latter method is more reliable since it reveals functional possibilities of the pancreas. Stimulants of pancreatic secretion can be administered to the duodenum or parenterally. The stimulants can be divided into two groups by their action on the pancreas. Some of them mostly intensify secretion and increase hydrocarbonate content in the secreted juice. Other stimulants do not in­crease the volume of secretion while the enzyme content increases significantly. Stimulants of the first group are hydrochloric acid, secretin, vegetable juices, and ether. Vegetable fat, pancreozymin, and insulin belong to the other group.

Hydrochloric acid and secretin (physiological stimulants) are most widely used in practical studies. As hydrochloric acid passes the stomach and enters the duodenum, it stimulates formation of secretin which is car­ried with the blood to the pancreas to activate its secretory function. The disadvantage of hydrochloric acid is that its presence in the duodenum stimulates formation not only of secretin but also of cholecystokinin, which in turn stimulates secretion of bile whose presence in the pancreatic juice distorts the results of the studies. Pure secretin introduced in­travenously (one clinical unit/kg body weight) is devoid of this disadvan­tage. Hydrochloric acid is however more readily available. Pancreozymin is often used in combination with secretin, which is administered 60 minutes later.

Procedure. The duodenal contents are obtained by a tube. A double-tube should be used: its one end opens in the stomach and the other in the duodenum. Better results are obtained with this tube because extraction of gastric juice during this procedure ensures better purity of the pancreatic juice. The position of the tubes should be controlled by X-rays. A water-jet pump is used for continuous suction of the gastric and duodenal contents. After a 30-minute aspiration of " spontaneous" pancreatic juice, 30 ml of warmed 0.5 per cent hydrochloric acid solution are introduced through the duodenal tube. The tube is then clamped for 5 minutes, and then six or

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Chapter 7. Digestive System

eight 10-minute portions of the juice are collected. If secretin is used as a stimulant, the juice is pumped immediately after the injection (10-minute portions as well) and studied.

The volume, colour, transparency, bilirubin concentration, hydrocar-bonate alkalinity, and enzyme activity are then determined in the obtained samples. Hydrocarbonate alkalinity is determined gasometrically (Van Slyke's apparatus). Bilirubin is determined by the icterus index. Amylase, trypsin, and lipase are determined in the pancreatic juice. Normally the en­zyme concentration in the juice decreases after administration of hydrochloric acid or secretin because the liquid fraction of the juice thus increases. But in 60-90 minutes, the concentration returns to initial. In in­sufficiency of the pancreas the initial enzyme concentration is restored more slowly. The content of separate enzymes sometimes changes as well. The pancreatic function is assesed not only by enzyme concentration, but also by the quantity of enzyme units isolated per unit time.

Study of enzymes in duodenal contents. Activity of amylase is deter­mined by the Wohlgemuth test — by the quantity of millilitres of a 1 per. cent starch solution that can be split by 1 ml of pancreatic juice. The duodenal contents are diluted in an isotonic sodium chloride solution in geometrical progression from 1: 10 to 1: 20 240. To 1 ml of each solution ad­ded are 2 ml of a 1 per cent starch solution. After a 30-minute incubation on a water bath at 37 °C, a drop of 1/50 N iodine solution is added to each test tube. The maximum dilution is determined by the absence of the blue colour which indicates that all starch has been split. Multiplying this dilu­tion by 2 (2 ml of starch solution were added) the quantity of amylase units is determined (normal, 640-1280).

Determining trypsin by the Fuld-Goss method. The procedure is the same as that used for determining amylase. The duodenal contents are diluted and 2 ml of a 0.1 per cent alkaline caseine is added to each 1-ml por­tion of the diluted solutions. After a 24-hour thermostatting at 37 °C, the solution in which all caseine has been split is found by the absence of cloudiness after adding a few drops of a 5 per cent acetic acid solution. The calculation is the same as in determining amylase. The normal activity of trypsin is 160-2500 units.

Determination of lipase by the Bondi method is based on the formation of fatty acids from fat split by lipase. Lipase activity is expressed by the quantity of millilitres of the alkali spent to neutralize fatty acids formed from olive oil by the action of 100 ml of the duodenal juice. Normal activi­ty of lipase is 50—60 units.

Study of the pancreatic enzymes in the blood and urine. The so-called deflection of pancreatic enzymes is of certain diagnostic importance. In some pathologies of the pancreas mainly associated with abnormal secre-

tion outflow, the pancreatic enzymes enter the blood and then the urine. Since urine and blood are easier obtained than the pancreatic juice, the clinical study of the pancreatic function usually begins with blood and urine tests. Amylase and lipase are first determined in them; trypsin and antitrypsin are determined in rare cases.

Amylase can be determined in blood and urine by the Wohlgemuth test as in the analysis of the duodenal juice, except that a weaker solution of starch (0.1 per cent) is used. More accurate results are obtained with the Smith-Roe method which is based on decomposition of starch by amylase (normally, 80-150 units in blood). The intensity of colour of the starch-iodine solution changes depending on the degree of starch hydrolysis (determined absorptiometrically).

Blood lipase is determined by the stalagmometric method which is based on the change in the surface tension of tributyrin solution under the action of fatty acids formed by the action of lipase. But several types of lipase are present in the blood; pancreatic and hepatic lipases prevail. Pan­creatic lipase is stable to atoxyl but is decomposed by quinine, while hepatic lipase is on the contrary stable to quinine and decomposed by atox­yl. The increased content of atoxyl-resistant lipase is important for the diagnosis of pancreas affections.

The endocrine function can also be affected in diseases of the pancreas. For special tests see " Diabetes Mellitus".

X-RAY EXAMINATION

Survey radiographs of the abdominal cavity reveal only separate stones in the pancreatic ducts or calcified tissues of the pancreas (due to chronic pancreatitis). These are projected in accordance with the anatomical loca­tion of the organ at the level of the 2nd-3rd lumbar vertebrae; or a large cyst is projected as a uniform distinctly outlined formation.

X-ray examination of the stomach and the duodenum can sometimes reveal indirect signs of tumours, cysts, and sometimes chronic pancreatitis. For example, in the presence of cancer, a cyst of the head of the pancreas or in pancreatitis attended by enlargement of the head, contrast radiography reveals dilation, deformation, and displacement of the duodenal loop. If a tumour (cyst) is localized in the body or tail of the pan­creas, the changes appear as defective filling in the region of the posterior wall or the greater curvature of the stomach due to pressure on it from the enlarged pancreas. Changes in the duodenum can be especially vivid if the gland is first relaxed (relaxation duodenography). To that end the patient is given intravenously 2 ml of a 0.1 per cent atropine sulphate solution and, intraintestinally (through a duodenal tube), barium sulphate suspension.

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Chapter 7. Digestive System

X-ray studies of the pancreas can also be carried out during duodenoscopy (retrograde pancreatography, wirsungography). A contrast substance is administered into the pancreatic duct. Depending on the character of the affection, non-uniform stenosis, dilation, or rupture of the bile duct can be seen on the X-ray picture.

To diagnose affections of the pancreas (tumours, cysts), angiography is also used with administration of the contrast substance through a tube into the coeliac artery, through the femoral artery, and further to the aorta.

RADIOISOTOPE METHODS OF STUDY

Methionine labelled with radioactive selenium (^Se—selenomethioni-ne) is used for scanning the pancreas. The radioactive solution (250 ^Ci) is given intravenously and scanning is taken in 30 minutes. The rate of ac­cumulation, time of the presence of the isotope in the pancreas, and the time of its delivery to the intestine together with the pancreatic secretion are also assessed.

In the presence of diffuse inflammatory and dystrophic changes in the pancreatic parenchyma, the absorption of labelled methionine in the pan­creas considerably decreases and a scanogram shows uneven (spotted) distribution of the isotopes; vast defective accumulation of the isotope in the pancreas is revealed in cysts and tumours of the pancreas.

ECHOGRAPHY

Echography is widely used in the study of the pancreas. One- and two-chamber techniques are used. The special value of echography in the study of the pancreas is that the gland is deeply located inside the abdomen and other methods of examination are inapplicable, except angiography and retrograde (through an endoscope) wirsungography, which furnish valuable diagnostic information. Echographic diagnosis is complicated by the great individual variability of position and size of the pancreas, pro­nounced meteorism, and obesity. Because of these difficulties, the pan­creas can be " seen" and examined only in 90 per cent of patients. The reflected echo-signals give the examiner the idea of the position, size, and condition of the pancreas. Echography is used to confirm the presence of acute or chronic pancreatitis, to establish the diagnosis, or to suspect the presence of a tumour (depending on the size, character and position, tumours are revealed in almost 80 per cent of cases). Cysts of the pancreas over 1.5—2 cm in size are revealed in almost 100 per cent of cases.

One-dimensional apparatus is used to examine the patient from his back; three groups of echo-signals appear on the screen: (1) generated im-

pulse; (2) impulses reflected from the skin, subcutaneous fat, and long muscles of the back; and (3) signals reflected from the pancreas appear on the oscilloscope screen as vertical peaks located above the zero line.