Faculty Bibliography

To determine the value of liver histology in predicting one-year survival after protal venous decompression, eight hepatic histologic features were evaluated prospectively in 53 patients. The presence of panlobular fat and of alcoholic hyaline were the only individual features having a significant correlation with outcome. When the predictive power of these histologic features was compared by linear logistic regression analysis to that of 28 clinical and laboratory variables, panlobular fat was the best single predictor, followed in sequence by admission prothrombin time, alcoholic hyaline, admission hematocrit, and Child's C classification. The combination of hematocrit and panlobular fat produced the best two-variable equation, predicting outcome in 79% of patients. No three-variable equation significantly improved upon the two-variable combination of hematocrit and panlobular fat. Therefore certain hepatic histologic features, alone or in combination with other factors, appear to be powerful predictors of one-year mortality. When liver biopsy is obtainable, histologic features should be considered in determining suitability for portasystemic shunt surgery.

Previous studies have reported that injection of duodenal extracts from rats fed different meals into the celiac artery of recipient rats elicited the secretion of related pancreatic enzymes. We have been unable to reproduce the enzyme-specific increases in the average output of particular enzymes that were observed but did find changes similar in direction, although not magnitude, to those reported previously. The outputs of amylase and trypsinogen were compared by plotting individual data points and performing a regression analysis on them. The injection of duodenal extracts from lactalbumin hydrolysate-fed rats led to trypsinogen secretion being favored over that of amylase and vice versa for extracts from rats fed a glucose meal. In addition, it was found that cholecystokinin-pancreozymin produced a dramatic nonparallel transport of these two enzymes with amylase secretion being augmented to a greater degree than trypsinogen secretion. The relation between their outputs was curvilinear, i.e., the amylase dominance of secretion became more pronounced as overall enzyme output (not dose of hormone) increased. Thus, this nonparallel secretion does not seem to be the results of a discontinuous switch in the character of enzyme secretion produced by the hormone but a graded effect reflecting the magnitude of the response.

The relation between plasma and biliary amylase activity and their relationship to the functional state of the pancreas were studied in anesthetized rabbits. Repetitive intravenous injections of cholecystokinin resulted in a 25-fold rise in the secretion of amylase via the pancreatic duct, followed at first by a 50% increase in plasma amylase concentration and later by a 270% increase in biliary amylase concentration. There was then a gradual, roughly synchronous decline in both plasma and biliary values toward basal level despite a continued highly augmented rate of pancreatic ductal secretion. "Near-total" pancreatectomy completely abolished the effect. These observations are consistent with a cholecystokinin-induced basolateral secretion of amylase from pancreas into blood and its subsequent movement from blood into bile down a concentration gradient. The output of amylase in bile, however, was quite small and does not suggest that biliary transport of amylase has an important function either as a means of secreting and recycling digestive enzyme into the gut or as a major excretory pathway for circulating amylase in the rabbit.

Two digestive end products, D-glucose and L-lysine, produced substantial concentration-dependent release of amylase and trypsinogen, respectively, from subcellular storage pools into a postmicrosomal supernatant fraction of rat pancreatic tissue homogenate. This process was selective in that D-glucose did not lead to trypsinogen release, while L-lysine did not effect amylase. An analogue of D-glucose, 2-deoxy-D-glucose, was much less potent than D-glucose on an equimolar basis. Half-maximal release for both end-product enzyme pairs occurred at concentrations within the range of normal plasma values for these end products in the rat. Although amylase release reached an apparent plateau when the concentration of glucose was increased beyond the maximally effective level, lysine concentrations higher than that maximally effective resulted in a fall in trypsinogen release that ultimately returned (at 3.0 mM L-lysine) to the level seen in its absence. When isolated zymogen granules were exposed to the same concentrations of D-glucose or L-lysine, a similar pattern of release was seen, indicating that the zymogen granules are a source of the enzymes released from the particulate phase of the homogenates. These findings can be explained most simply by the selective movement of digestive enzymes across zymogen granule membranes in response to the presence of appropriate end products. They are also consistent with the concept that digestive end products can act rapidly and directly on the pancreatic acinar cell to regulate the mixture of enzymes secreted in response to the specific hydrolytic needs of a meal.

We studied 12 patients who had had endoscopically proved erosive duodenitis and a radiographic examination of the upper gastrointestinal (UGI) tract, which had been performed within 2 weeks of endoscopy. Radiographic criteria for erosive duodenitis were established by two radiologists and consisted of spasm, thickening of duodenal folds, erosions, and ulcers. Using these criteria, two other radiologists interpreted the radiographs of the 12 patients with duodenitis 15 others with normal duodenums, and five with pancreatic disease. They made correct diagnoses for eight of the patients with erosive duodenitis, nine with normal duodenums, and three with pancreatic disease. A third radiologist interpreted only the 12 misdiagnosed radiographs; he was correct only for three cases of duodenitis. Analysis of these results show that radiographic diagnosis of erosive duodenitis can be made only in advanced disease.

Granuloma faciale is a presumably benign disorder of the skin--usually of the face--characterized by a dense, polymorphous, inflammatory infiltrate including numerous eosinophils, separated from the epidermis by a clear or "grenz" zone, and possessing a small vessel, leukocytoclastic vasculitis. Primary malignant lymphoma of the skin, other than mycosis fungoides, is an unusual entity that may follow a widely variable course and is often extremely difficult to diagnose definitively. A patient is presented in whom a lesion consistent with granuloma faciale changed its histological appearance and clinical behavior into that of a malignant lymphoma.