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Gastric and Pancreatic function tests

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The slides show the gastric and pancreatic function test along with the significance of these tests and the conditions in which the values of which increase.

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Gastric and Pancreatic function tests

  1. 1. Gastric and pancreatic function tests
  2. 2. Gastric function test Out Line  Chief constituents of gastric juice  Stages of gastric secretion  Inhibition of gastric secretion  Why gastric function test are important?  Tests of gastric function with interpretation
  3. 3. Chief constituents of gastric juice • Hydrochloric acid • Pepsinogen • Intrinsic factor • Gastric mucus • Blood group substances • Rennin
  4. 4. Stimulation of gastric secretion • Cephalic Phase: Site, taste, smell, thought of food, insulin. Stimulation through vagus nerve. • Gastric Phase: Food in the stomach local reflexes Vagal activity acetylcholine gastrin from mucosa of pylorus parietal & chief cells hydrochloric acid, pepsinogen, gastric motility.
  5. 5. Inhibition of gastric secretion • Entry of food into the duodenum. • Secretin, cholecystokinin-pancreozymin • Gastric Inhibitory peptide • Vasoactive Intestinal Peptide
  6. 6. Why gastric function test are important? • Zolliger-Ellison Syndrome • Evaluate pernicious anemia in adults • Type of surgical procedure required for ulcer treatment.
  7. 7. Stimulants for gastric secretion • Ewald one hour meal: toast without butter, tea without milk • Fractional test meal of Rehffus: Pint of oat meal gruel
  8. 8. • Histamine test: Histamine hydrochloride 0.25mg/kg subcutaneously. • Augumented histamine test: 0.04mg/kg histamine is given subcutaneously along with antihistamine. • Histolog. • Pentagastrin • Insulin
  9. 9. Titrimetric analysis of acid output • Titrate 5ml of gastric contents with 100mmol/L NaOH either to pH 7.4 using glass electrode or to an end point with phenol red. Acid output in mmol/h = ml of NaOH volume of specimen in ml 6 ml of gastric period of collection juice titrated in minutes
  10. 10. Gastric acidity curves Total acidity Free acidity Hypoacidity Hyperacidity Combined acidity
  11. 11. The Pentagastrin test • Maximal stimulation of the stomach after assessment of basal secretion rate. • Measure of total parietal cell mass. • Technique
  12. 12. 12 hour fasting without food & drink Pass nasogastric tube tube & site it radiologically with tip in the gastric antrum. Place the patient in recumbent position. Empty the stomach completely with hand syringe by pressure ≤ 50mmHg Collect two 15min specimens to give basal secretion Pentagastrin subcutaneous injection 6µg/kg Collect four accurately timed 15min specimens Measure the volume, pH, acid content of 6 specimens, inspect fasting contents for blood & bile pigments
  13. 13. Interpretation • It may suggest appropriate measures in active duodenal ulcer, pernicious anemia & in Zolliger- Ellison Syndrome. • Normal basal secretion: 1 – 2.5mmol/h • Normal range of maximal secretion: 20 – 40mmol/h • Zolliger- Ellison Syndrome: basal secretion is >10mmol/h & no further rise after giving pentagastrin.
  14. 14. • Achlorhydria is seen in gastric cancer, pernicious anemia. pH will be above 6. • acute and chronic gastritis.
  15. 15. Insulin Stimulation test • Insulin hypogycemia is a potent stimulus of acid secretion. • When blood sugar is < 50.0mg/dl (2.8mmol/L) vagus is stimulated by hypoglycemia. • This test is best limited to those patients suspected to have recurrent ulceration after vagotomy which was probably incomplete. • Technique
  16. 16. 12 hour fasting without food & drink Pass nasogastric tube & site it radiologically with tip in the gastric antrum. Place the patient in recumbent position. Empty the stomach completely with hand syringe by pressure ≤ 50mmHg Collect four 15min specimens to give basal secretion, determine venous blood glucose immediately Insulin intravenous injection 0.2U/kg Collect eight accurately timed 15min specimens & determine venous blood glucose at 30 & 45 minutes Measure the volume, pH, acid content of 12 specimens, inspect fasting contents for blood.
  17. 17. Interpretation • Before operation for vagotomy there is marked & prolonged rise in acid over 100mmol/L. After successful vagotomy there is no response or only fluctuation in the baseline. • Basal secretion 10mmol/L • Basal secretion > 20mmol/L suggest incomplete section of vagus.
  18. 18. Plasma Gastrin • Valuable in diagnosis of Zolliger- Ellison Syndrome. • Normal plasma concentration: 50 – 150pg/ml. • Zolliger- Ellison Syndrome: 1000 – 400,000pg/ml. • Not increased in simple peptic ulcer. • Increased in pernicious anemia.
  19. 19. Tubeless gastric analysis • Segal et al 1953 demonstrated direct HCl secretion without intubation by Diagnex blue. • Principle: Orally administered quinimum resin indicator forms quinine in the stomach at pH <3 and quinine hydrochloride is generated. This is then absorbed in the small intestine, excreted in the urine. Quninine was extracted from the urine and determined florimetrically. • Procedure
  20. 20. 12 hour fasting After voiding administer orally caffeine Na benzoate with water After 1 h urine is collected as control sample administer orally Diagnex blue with water After 2 h urine is collected as test sample 2 samples are compared in a colour comparator with 0.3mg & 0.6mg Azur-A standards Acidify the urine
  21. 21. Interpretation Observation (Colour intensity) Inference <0.3mg std Achlorhydria 0.3mg to 0.6mg std Hypochlorhydria
  22. 22. Limitations • It is only a screening test to assesss gastric acid secretion. • Test is not reliable in patient suffering from pyloric obstruction, malabsorption, renal disease, urinary retention, liver disease, subtotal gastrectomy, gastroenterostomy, pyloroplasty. • Vitamin preparation should be avoided on the day preceeding the test or medicaments given which might contain substances decolorised by ascorbic acid.
  23. 23. Test for Occult blood in the feces • Definition: Tests to detect blood in feces in amounts or forms not observable on inspection are referred as occult blood test. • Normal blood loss in the feces 2.5ml/day by radiochrome studies. Blood may be introduced from mouth, around teeth, minor abrasion in the GI tract by roughage of food, hemoglobin, myoglobin, their breakdown products, peroxidases of plant & bacterial origin.
  24. 24. • Benzedine test was commonly used, now prevented because of its carcinogenecity. O-toluidine is used with three different concentrations: 4%, 1.2% & 0.4% in glacial acetic acid. • Principle: hemoglobin & its derivatives H2O2 H2O O2+ O-Toluidine Coloured product (Measured colorimetrically)
  25. 25. Test procedure • A small portion of feces mixed in 10ml DW & boil for a minute to destroy peroxidases. Mix fecal suspension + reagent (O-toluidine & H2O2) • Blue colour --- Positive test. • If a single concentration was used 1.2% recommended. • If all three used 1st 4% used, positive samples tried with 1.2%, still positive samples tried with 0.4%.
  26. 26. Reporting Negative -ve with 4% Weakly positive +ve only with 4% Strongly positive +ve with 4%, 1.2%, 0.4%
  27. 27. Interpretation • Test is mainly used in the diagnosis & treament of ulcers, cancer of stomach, gastritis, perpura, lesion in duodenum, small & large intestine. • In case of humorrhoids blood can be seen as streeks of fresh blood on the surface of feces confirmed by misroscopic examinations. • It is also useful practice to do the test on three successive days when the patient is on meat free diet.
  28. 28. • Oxyhaemoglobin released from bleeding converted to hematin & porphyrin by gastric HCl. Only hematin gives the positive test. • In case bleeding lower down the alimentary tract, Oxyhaemoglobin released can be recognised by spectroscopic examination of supernatant fluid from a centrifuged fecal suspension. • Does not afford any information about bleeding from mouth, nose, throught & the type of lesion present.
  29. 29. Out Line Exocrine secretions of Pancrease Tests in Pancreatic Diseases with interpretation Determination of [HCO3 - ] Amylase (AMS) Essay of AMS activity Macroamylasemia Isoenzymes of AMS Renal clearance of AMS Lipase (LPS) Assay of LPS activity
  30. 30. Exocrine secretions of Pancrease Inorganic Organic NaHCO3(127mmol/L) α - amylase Na+ (135-145mmol/L) Lipase K+ (3.4-5.0mmol/L) Trypsin Mg+ , Ca+2 , Zn+ (less) Chymotripsin Cl- (155mmol/L) Carboxipeptidase A & B Ribonucleases Deoxyribonucleases Cholesterolesterases Phospholipases
  31. 31. Tests in Pancreatic Diseases Introduction • Measurement of total volume. • Concentration of HCO3 - • Chemical & cytological examinations performed support suspicion of malignant neoplasm, but exact localization may be unknown. • Secretin/ CCK-PZ test: Technique
  32. 32. 12 hour fasting without food & drink Pass the double lumen tube & site it radiologically with tip of inner tube in the 3rd part of duodenum. Clear bile stained juice (two 10min samples) from the deuodenal tube & juice free from bile from gastric tube were collected as basal secretion. 2-3U/kg Secretin/CCK-PZ administred intravenously over 2 min. Pancreatic secretions are collected for 30, 60, 80 minutes. pH, secretory rate, [HCO3 - ] are measured.
  33. 33. Determination of [HCO3 - ] • To 5ml duodenal juice add 10ml of 100mmol/l HCl in a small beaker, boil to expel CO2, cool & titrate with 100mmol/l NaOH to pH 7.0 by a glass electrode or to an end point with phenolphthalein indictor. • [HCO3 - ] in mmol/l = (Vol. of HCl – Vol. of NaOH) 20
  34. 34. Interpretation • Normal [HCO3 - ] = 127mmol/L • Secretory rate: • Men: 15mmol/h • Women: 12mmol/h Rate found in pancreatic obstruction with enzyme concentration. [HCO3 - ] and enzymes associated with cystic fibrosis, chronic pancreatitis, pancreatic cysts, calcification & edema of the pancreas.
  35. 35. Amylase (AMS) • Tissue source: acinar cells of pancreas & salivary glands. Lesser concentration in skeletal muscle, small intestine, fallopian tube. • This is the smallest enzyme readily filtered through the renal glomerulus & appears in the urine.
  36. 36. Essay of AMS activity • Amyloclastic method. • Saccharogenic method. • Chromogenic method. • Continuous monitering method.
  37. 37. Amyloclastic method Starch + iodine = AMS Isomaltose, maltose, glucose blue coloured complex blue coloured complex Measure colour intensity colorimetrically
  38. 38. Saccharogenic method Starch Isomaltose & maltose AMS (reducing sugars)  Reducing sugar is then measured with high alkalinity copper reagent.  The values are expressed in somogyi units.  Somogyi units are an expression of the number of mg of glucose released in 30 min under specific assay condition.
  39. 39. Chromogenic method Starch with chromognic dye AMS Starch broken down to release chromognic dye (insoluble dye) (soluble dye) Measure colour intensity colorimetrically
  40. 40. Continuous monitoring • Coupled enzyme system: change in the absorbance of NAD+ at 340nm is measured. Maltopentose Maltotriose + Maltose Maltotriose + Maltose 5 glucose 5 glucose + 5 ATP 5 glucose-6-P + 5 ADP 5 glucose-6-P + 5, 6-phophogluconolactone + 5 NAD+ 5 NADH AMS α-glucosidase Hexokinase G6PDH
  41. 41. Interpretation • Reference ranges of AMS: • Serum: 25 – 130U/L. • Urine: 1 – 15U/L. • Approximate conversion factor between somogyi units & international units is 1.85 • In acute pancreatitis AMS begin to rise 2 – 12 h after the onset of attack, peak at 24h & return to normal within 3 – 5 days. Values generally varies between 250 – 1000 somogyi units/dl.
  42. 42. • In salivary gland lesion, mumps, parotitis, perforated peptic ulcer, intestinal obstruction, cholecystitis, ruptured ectopic pregnancy, mesenteric infarction, acute appendicitis, renal insufficiency, diabetic ketoacedosis. • Serum AMS other than acute pancreatitis are usually less than 500 somogyi units/dl.
  43. 43. Macroamylasemia (asymptomatic) • Diagnostic significance: Differentiate macroamylasemia from hyperamylasemia. ImmunoglobulinAMS + Big complex (Can not be filtered through glomerular membrane)
  44. 44. Isoenzymes of AMS • P-type: pancreatic • S- type: salivary, fallopian tube, lung • Isoenzymes of salivary origin migrate most quickly (S1, S2, S3), where as pancreatic origin move slower (P1, P2, P3). • AMS migrate in the regions corresponding to β to α- globulin regions of the protein. • P-type activity, specifically P3 in acute pancreatitis
  45. 45. Renal clearance of AMS • Useful in detecting minor or intermittent in serum concentration. • Normal Values: < 3.1% • Acute pancreatitis: 8% - 9% • Also in burns, sepsis, diabetic ketoacedosis. % AMS clearance Creatinine clearance= 100 UA SC SA UC × ×
  46. 46. Lipase (LPS) Assay by titrimetric method: • Tissue source: primarily in pancreas, little in stomach & small intestine. • Classical Cherry-Crandall method used an olive oil substrate & measured the liberated FA by tritration after 24h incubation. Trioline is one of the substance now used as a more pure form of TAG. triglyceride+ 2H2O LPS pH 8.6-9 2-monoglyceride+2-fatty acid
  47. 47. Turbidimetric method Fats in solution (cloudy emulsion) LPS Hydrolysed fat in solution (Fat particles disperse) Rate of clearing of the fat in the solution is measured.
  48. 48. Interpretation • Reference range: 0 – 1.0U/ml • This is exclusive for the diagnosis of acute pancreatitis. • Both AMS & LPS levels rise quickly, but LPS elevation persist for 5 days, whereas AMS only for 2 – 3 days. • Elevated also in penetrating duodenal ulcer, intestinal obstruction, acute cholecystitis.
  49. 49. • In contrast to AMS levels, LPS levels are normal in conditions of salivary gland involvement. • Of the three LPS isoenzymes, L2 is thought to be most clinically specific & sensitive.

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