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Erschienen in: Wiener Medizinische Wochenschrift 3-4/2014

01.02.2014 | main topic

An update on pancreatic pathophysiology (Do we have to rewrite pancreatic pathophysiology?)

verfasst von: Univ. Prof. Dr. Heinz F. Hammer

Erschienen in: Wiener Medizinische Wochenschrift | Ausgabe 3-4/2014

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Summary

This review focuses on seven aspects of physiology and pathophysiology of the exocrine pancreas that have been intensively discussed and studied within the past few years: (1) the role of neurohormonal mechanisms like melatonin, leptin, or ghrelin in the stimulation of pancreatic enzyme secretion; (2) the initiation processes of acute pancreatitis, like fusion of zymogen granules with lysosomes leading to intracellular activation of trypsinogen by the lysosomal enzyme cathepsin B, or autoactivation of trypsinogen; (3) the role of genes in the pathogenesis of acute pancreatitis; (4) the role of alcohol and constituents of alcoholic beverages in the pathogenesis of acute pancreatitis; (5) the role of pancreatic hypertension, neuropathy, and central mechanisms for the pathogenesis of pain in chronic pancreatitis; (6) the relation between exocrine pancreatic function and diabetes mellitus; and (7) pathophysiology, diagnosis and treatment of pancreatic steatorrhea.
Literatur
1.
Zurück zum Zitat Jaworek J, Nawrot-Porabka K, Leja-Szpak A, Konturek SJ. Brain-gut axis in the modulation of pancreatic enzyme secretion. J Physiol Pharmacol. 2010;61:523–31.PubMed Jaworek J, Nawrot-Porabka K, Leja-Szpak A, Konturek SJ. Brain-gut axis in the modulation of pancreatic enzyme secretion. J Physiol Pharmacol. 2010;61:523–31.PubMed
2.
Zurück zum Zitat Rehfeld JF, Friis-Hansen L, Goetze JP, Hansen TV. The biology of cholecystokinin and gastrin peptides. Curr Top Med Chem. 2007;7:1154–65.PubMedCrossRef Rehfeld JF, Friis-Hansen L, Goetze JP, Hansen TV. The biology of cholecystokinin and gastrin peptides. Curr Top Med Chem. 2007;7:1154–65.PubMedCrossRef
3.
Zurück zum Zitat Mössner J. New advances in cell physiology and pathophysiology of the exocrine pancreas. Dig Dis. 2010;28:722–8.PubMedCrossRef Mössner J. New advances in cell physiology and pathophysiology of the exocrine pancreas. Dig Dis. 2010;28:722–8.PubMedCrossRef
4.
Zurück zum Zitat Morisset J. Negative control of human pancreatic secretion: physiological mechanisms and factors. Pancreas. 2008;37:1–12.PubMedCrossRef Morisset J. Negative control of human pancreatic secretion: physiological mechanisms and factors. Pancreas. 2008;37:1–12.PubMedCrossRef
5.
Zurück zum Zitat Love JA, Yi E, Smith TG. Autonomic pathways regulating pancreatic exocrine secretion. Auton Neurosci. 2007;133:19–39.PubMedCrossRef Love JA, Yi E, Smith TG. Autonomic pathways regulating pancreatic exocrine secretion. Auton Neurosci. 2007;133:19–39.PubMedCrossRef
6.
Zurück zum Zitat Gaisano HY, Gorelick FS. New insights into the mechanisms of pancreatitis. Gastroenterology. 2009;136:2040–4.PubMedCrossRef Gaisano HY, Gorelick FS. New insights into the mechanisms of pancreatitis. Gastroenterology. 2009;136:2040–4.PubMedCrossRef
7.
Zurück zum Zitat Sherwood MW, Prior IA, Voronina SG, Barrow SL, Woodsmith JD, Gerasimenko OV, Petersen OH, Tepikin AV. Activation of trypsinogen in large endocytic vacuoles of pancreatic acinar cells. Proc Natl Acad Sci USA. 2007;104:5674–9.PubMedCentralPubMedCrossRef Sherwood MW, Prior IA, Voronina SG, Barrow SL, Woodsmith JD, Gerasimenko OV, Petersen OH, Tepikin AV. Activation of trypsinogen in large endocytic vacuoles of pancreatic acinar cells. Proc Natl Acad Sci USA. 2007;104:5674–9.PubMedCentralPubMedCrossRef
8.
Zurück zum Zitat Norman J. The role of cytokines in the pathogenesis of acute pancreatitis. Am J Surg. 1998;175:76–83.PubMedCrossRef Norman J. The role of cytokines in the pathogenesis of acute pancreatitis. Am J Surg. 1998;175:76–83.PubMedCrossRef
9.
Zurück zum Zitat Gloor B, Reber HA. Effects of cytokines and other inflammatory mediators on human acute pancreatitis. J Int Care Med. 1998;13:305–12.CrossRef Gloor B, Reber HA. Effects of cytokines and other inflammatory mediators on human acute pancreatitis. J Int Care Med. 1998;13:305–12.CrossRef
10.
Zurück zum Zitat Tenner S, Sica G, Hughes M, Noordhoek E, Feng S, Zinner M, Banks PA. Relationship of necrosis to organ failure in severe acute pancreatitis. Gastroenterology. 1997;113:899–903.PubMedCrossRef Tenner S, Sica G, Hughes M, Noordhoek E, Feng S, Zinner M, Banks PA. Relationship of necrosis to organ failure in severe acute pancreatitis. Gastroenterology. 1997;113:899–903.PubMedCrossRef
11.
Zurück zum Zitat Beger HG, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis. A prospective clinical study. Gastroenterology. 1986;91:433–8.PubMed Beger HG, Bittner R, Block S, Büchler M. Bacterial contamination of pancreatic necrosis. A prospective clinical study. Gastroenterology. 1986;91:433–8.PubMed
12.
Zurück zum Zitat Beger HG, Rau B, Mayer J, Pralle U. Natural course of acute pancreatitis. World J Surg. 1997;21:130–5.PubMedCrossRef Beger HG, Rau B, Mayer J, Pralle U. Natural course of acute pancreatitis. World J Surg. 1997;21:130–5.PubMedCrossRef
13.
Zurück zum Zitat Bassi C, Falconi M, Girelli R, Nifosi F, Elio A, Martini N, Pederzoli P. Microbiological findings in severe pancreatitis. Surg Res Commun. 1989;5:1–4. Bassi C, Falconi M, Girelli R, Nifosi F, Elio A, Martini N, Pederzoli P. Microbiological findings in severe pancreatitis. Surg Res Commun. 1989;5:1–4.
14.
Zurück zum Zitat Tonsi AF, Bacchion M, Crippa S, Malleo G, Bassi C. Acute pancreatitis at the beginning of the 21st century: the state of the art. World J Gastroenterol. 2009;15:2945–59.PubMedCentralPubMedCrossRef Tonsi AF, Bacchion M, Crippa S, Malleo G, Bassi C. Acute pancreatitis at the beginning of the 21st century: the state of the art. World J Gastroenterol. 2009;15:2945–59.PubMedCentralPubMedCrossRef
15.
Zurück zum Zitat Mooren FC, Hlouschek V, Finkes T, Turi S, Weber IA, Singh J, Domschke W, Schnekenburger J, Krüger B, Lerch MM. Early changes in pancreatic acinar cell calcium signaling after pancreatic duct obstruction. J Biol Chem. 2003;278:9361–9.PubMedCrossRef Mooren FC, Hlouschek V, Finkes T, Turi S, Weber IA, Singh J, Domschke W, Schnekenburger J, Krüger B, Lerch MM. Early changes in pancreatic acinar cell calcium signaling after pancreatic duct obstruction. J Biol Chem. 2003;278:9361–9.PubMedCrossRef
16.
Zurück zum Zitat Chaudhuri A, Kolodecik TR, Gorelick FS. Effects of increased intracellular cAMP on carbachol-stimulated zymogen activation, secretion, and injury in the pancreatic acinar cell. Am J Physiol Gastrointest Liver Physiol. 2005;288:G235–43. Chaudhuri A, Kolodecik TR, Gorelick FS. Effects of increased intracellular cAMP on carbachol-stimulated zymogen activation, secretion, and injury in the pancreatic acinar cell. Am J Physiol Gastrointest Liver Physiol. 2005;288:G235–43.
17.
Zurück zum Zitat Mössner J. Update lecture: benign diseases of the exocrine pancreas. Dig Dis. 2011;29(Suppl. 1):9–16.PubMedCrossRef Mössner J. Update lecture: benign diseases of the exocrine pancreas. Dig Dis. 2011;29(Suppl. 1):9–16.PubMedCrossRef
18.
Zurück zum Zitat Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. 2010;139:813–20.PubMedCrossRef Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. 2010;139:813–20.PubMedCrossRef
19.
Zurück zum Zitat Teich N, Mössner J. Hereditary chronic pancreatitis. Best Pract Res Clin Gastroenterol. 2008;2:115–30.CrossRef Teich N, Mössner J. Hereditary chronic pancreatitis. Best Pract Res Clin Gastroenterol. 2008;2:115–30.CrossRef
20.
Zurück zum Zitat Whitcomb DC, Gorry MC, Preston RA, Furey W, Sossenheimer MJ, Ulrich CD, Martin SP, Gates LK Jr, Amann ST, Toskes PP, Liddle R, McGrath K, Uomo G, Post JC, Ehrlich GD. Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene. Nat Genet. 1996;14:141–5.PubMedCrossRef Whitcomb DC, Gorry MC, Preston RA, Furey W, Sossenheimer MJ, Ulrich CD, Martin SP, Gates LK Jr, Amann ST, Toskes PP, Liddle R, McGrath K, Uomo G, Post JC, Ehrlich GD. Hereditary pancreatitis is caused by a mutation in the cationic trypsinogen gene. Nat Genet. 1996;14:141–5.PubMedCrossRef
21.
Zurück zum Zitat Sharer N, Schwarz M, Malone G, Howarth A, Painter J, Super M, Braganza J. Mutations of the cystic fibrosis gene in patients with chronic pancreatitis. N Engl J Med. 1998;339:645–52.PubMedCrossRef Sharer N, Schwarz M, Malone G, Howarth A, Painter J, Super M, Braganza J. Mutations of the cystic fibrosis gene in patients with chronic pancreatitis. N Engl J Med. 1998;339:645–52.PubMedCrossRef
22.
Zurück zum Zitat Cohn JA, Friedman KJ, Noone PG, Knowles MR, Silverman LM, Jowell PS. Relation between mutations of the cystic fibrosis gene and idiopathic pancreatitis. N Engl J Med. 1998;339:653–8.PubMedCrossRef Cohn JA, Friedman KJ, Noone PG, Knowles MR, Silverman LM, Jowell PS. Relation between mutations of the cystic fibrosis gene and idiopathic pancreatitis. N Engl J Med. 1998;339:653–8.PubMedCrossRef
23.
Zurück zum Zitat Witt H, Luck W, Hennies HC, Classen M, Kage A, Lass U, Landt O, Becker M. Mutations in the gene encoding the serine protease inhibitor, Kazal type 1 are associated with chronic pancreatitis. Nat Genet. 2000;25:213–6.PubMedCrossRef Witt H, Luck W, Hennies HC, Classen M, Kage A, Lass U, Landt O, Becker M. Mutations in the gene encoding the serine protease inhibitor, Kazal type 1 are associated with chronic pancreatitis. Nat Genet. 2000;25:213–6.PubMedCrossRef
24.
Zurück zum Zitat Rosendahl J, Witt H, Szmola R, Bhatia E, Ozsvári B, Landt O, Schulz HU, Gress TM, Pfützer R, Löhr M, Kovacs P, Blüher M, Stumvoll M, Choudhuri G, Hegyi P, te Morsche RH, Drenth JP, Truninger K, Macek M Jr, Puhl G, Witt U, Schmidt H, Büning C, Ockenga J, Kage A, Groneberg DA, Nickel R, Berg T, Wiedenmann B, Bödeker H, Keim V, Mössner J, Teich N, Sahin-Tóth M. Chymotrypsin C (CTRC) variants that diminish activity or secretion are associated with chronic pancreatitis. Nat Genet. 2008;40:78–82.PubMedCentralPubMedCrossRef Rosendahl J, Witt H, Szmola R, Bhatia E, Ozsvári B, Landt O, Schulz HU, Gress TM, Pfützer R, Löhr M, Kovacs P, Blüher M, Stumvoll M, Choudhuri G, Hegyi P, te Morsche RH, Drenth JP, Truninger K, Macek M Jr, Puhl G, Witt U, Schmidt H, Büning C, Ockenga J, Kage A, Groneberg DA, Nickel R, Berg T, Wiedenmann B, Bödeker H, Keim V, Mössner J, Teich N, Sahin-Tóth M. Chymotrypsin C (CTRC) variants that diminish activity or secretion are associated with chronic pancreatitis. Nat Genet. 2008;40:78–82.PubMedCentralPubMedCrossRef
25.
Zurück zum Zitat Spanier BW, Dijkgraaf MG, Bruno MJ. Epidemiology, aetiology and outcome of acute and chronic pancreatitis: an update. Best Pract Res Clin Gastroenterol. 2008;22:45–63.PubMedCrossRef Spanier BW, Dijkgraaf MG, Bruno MJ. Epidemiology, aetiology and outcome of acute and chronic pancreatitis: an update. Best Pract Res Clin Gastroenterol. 2008;22:45–63.PubMedCrossRef
26.
Zurück zum Zitat Ammann RW. The natural history of alcoholic chronic pancreatitis. Intern Med. 2001;40:368–75.PubMedCrossRef Ammann RW. The natural history of alcoholic chronic pancreatitis. Intern Med. 2001;40:368–75.PubMedCrossRef
27.
Zurück zum Zitat Chowdhury P, Gupta P. Pathophysiology of alcoholic pancreatitis: an overview. World J Gastroenterol. 2006;12:7421–7.PubMed Chowdhury P, Gupta P. Pathophysiology of alcoholic pancreatitis: an overview. World J Gastroenterol. 2006;12:7421–7.PubMed
28.
Zurück zum Zitat Schneider A, Whitcomb DC, Singer MV. Animal models in alcoholic pancreatitis—what can we learn? Pancreatology. 2002;2:189–203.PubMedCrossRef Schneider A, Whitcomb DC, Singer MV. Animal models in alcoholic pancreatitis—what can we learn? Pancreatology. 2002;2:189–203.PubMedCrossRef
29.
Zurück zum Zitat Apte MV, Pirola RC, Wilson JS. Molecular mechanisms of alcoholic pancreatitis. Dig Dis. 2005;23:232–40.PubMedCrossRef Apte MV, Pirola RC, Wilson JS. Molecular mechanisms of alcoholic pancreatitis. Dig Dis. 2005;23:232–40.PubMedCrossRef
30.
Zurück zum Zitat Apte MV, Pirola RC, Wilson JS. Individual susceptibility to alcoholic pancreatitis. J Gastroenterol Hepatol. 2008;23(Suppl. 1):S63–8.PubMedCrossRef Apte MV, Pirola RC, Wilson JS. Individual susceptibility to alcoholic pancreatitis. J Gastroenterol Hepatol. 2008;23(Suppl. 1):S63–8.PubMedCrossRef
31.
Zurück zum Zitat Gerloff A, Feick P, Singer MV. Pancreas—non-alcoholic constituents and their effects. Dig Dis. 2010;28:812–9.PubMedCrossRef Gerloff A, Feick P, Singer MV. Pancreas—non-alcoholic constituents and their effects. Dig Dis. 2010;28:812–9.PubMedCrossRef
32.
Zurück zum Zitat Pezilli R, Morselli-Labate AM. Alcoholic pancreatitis: pathogenesis, incidence and treatment with special reference to the associated pain. Int J Environ Res Public Health. 2009;6:2763–82.CrossRef Pezilli R, Morselli-Labate AM. Alcoholic pancreatitis: pathogenesis, incidence and treatment with special reference to the associated pain. Int J Environ Res Public Health. 2009;6:2763–82.CrossRef
33.
Zurück zum Zitat Vardanyan M, Rilo HL. Pathogenesis of chronic pancreatitis-induced pain. Discov Med. 2010;9:304–10.PubMed Vardanyan M, Rilo HL. Pathogenesis of chronic pancreatitis-induced pain. Discov Med. 2010;9:304–10.PubMed
34.
Zurück zum Zitat Ebbehoj N, Svendsen LB, Madsen P. Pancreatic tissue pressure: techniques and pathophysiological aspects. Scand J Gastroenterol. 1984;19:1066–8.PubMed Ebbehoj N, Svendsen LB, Madsen P. Pancreatic tissue pressure: techniques and pathophysiological aspects. Scand J Gastroenterol. 1984;19:1066–8.PubMed
35.
Zurück zum Zitat Vestergaard H, Kruse A, Rokkjaer M, Frøbert O, Thommesen P, Funch-Jensen P. Endoscopic manometry of the sphincter of Oddi and the pancreatic and biliary ducts in patients with chronic pancreatitis. Scand J Gastroenterol. 1994;29:188–92.PubMedCrossRef Vestergaard H, Kruse A, Rokkjaer M, Frøbert O, Thommesen P, Funch-Jensen P. Endoscopic manometry of the sphincter of Oddi and the pancreatic and biliary ducts in patients with chronic pancreatitis. Scand J Gastroenterol. 1994;29:188–92.PubMedCrossRef
36.
Zurück zum Zitat Morgan DE, Smith JK, Hawkins K, Wilcox CM. Endoscopic stent therapy in advanced chronic pancreatitis: relationships between ductal changes, clinical response, and stent patency. Am J Gastroenterol. 2003;98:821–6.PubMedCrossRef Morgan DE, Smith JK, Hawkins K, Wilcox CM. Endoscopic stent therapy in advanced chronic pancreatitis: relationships between ductal changes, clinical response, and stent patency. Am J Gastroenterol. 2003;98:821–6.PubMedCrossRef
37.
Zurück zum Zitat Bradley EL 3rd. Long-term results of pancreatojejunostomy in patients with chronic pancreatitis. Am J Surg. 1987;153:207–13.PubMedCrossRef Bradley EL 3rd. Long-term results of pancreatojejunostomy in patients with chronic pancreatitis. Am J Surg. 1987;153:207–13.PubMedCrossRef
38.
Zurück zum Zitat Keith RG, Keshavjee SH, Kerenyi NR. Neuropathology of chronic pancreatitis in humans. Can J Surg. 1985;28:207–11.PubMed Keith RG, Keshavjee SH, Kerenyi NR. Neuropathology of chronic pancreatitis in humans. Can J Surg. 1985;28:207–11.PubMed
39.
Zurück zum Zitat Friess H, Shrikhande S, Shrikhande M, Martignoni M, Kulli C, Zimmermann A, Kappeler A, Ramesh H, Büchler M. Neural alterations in surgical stage chronic pancreatitis are independent of the underlying aetiology. Gut. 2002;50:682–6.PubMedCentralPubMedCrossRef Friess H, Shrikhande S, Shrikhande M, Martignoni M, Kulli C, Zimmermann A, Kappeler A, Ramesh H, Büchler M. Neural alterations in surgical stage chronic pancreatitis are independent of the underlying aetiology. Gut. 2002;50:682–6.PubMedCentralPubMedCrossRef
40.
Zurück zum Zitat Talukdar R, Saikia N, Singal DK, Tandon R. Chronic pancreatitis: evolving paradigms. Pancreatology. 2006;6:440–9.PubMedCrossRef Talukdar R, Saikia N, Singal DK, Tandon R. Chronic pancreatitis: evolving paradigms. Pancreatology. 2006;6:440–9.PubMedCrossRef
41.
Zurück zum Zitat Demir IE, Tieftrunk E, Maak M, Friess H, Ceyhan GO. Pain mechanisms in chronic pancreatitis: of a master and his fire. Langenbecks Arch Surg. 2011;396:151–60.PubMedCentralPubMedCrossRef Demir IE, Tieftrunk E, Maak M, Friess H, Ceyhan GO. Pain mechanisms in chronic pancreatitis: of a master and his fire. Langenbecks Arch Surg. 2011;396:151–60.PubMedCentralPubMedCrossRef
42.
Zurück zum Zitat Dimcevski G, Sami SA, Funch-Jensen P, Le Pera D, Valeriani M, Arendt-Nielsen L, Drewes AM. Pain in chronic pancreatitis: the role of reorganization in the central nervous system. Gastroenterology. 2007;132:1546–56.PubMedCrossRef Dimcevski G, Sami SA, Funch-Jensen P, Le Pera D, Valeriani M, Arendt-Nielsen L, Drewes AM. Pain in chronic pancreatitis: the role of reorganization in the central nervous system. Gastroenterology. 2007;132:1546–56.PubMedCrossRef
43.
Zurück zum Zitat Hardt PD, Ewald N. Exocrine pancreatic insufficiency in diabetes mellitus: a complication of diabetic neuropathy or a different type of diabetes? Exp Diabetes Res. 2011;2011:761950.PubMedCentralPubMedCrossRef Hardt PD, Ewald N. Exocrine pancreatic insufficiency in diabetes mellitus: a complication of diabetic neuropathy or a different type of diabetes? Exp Diabetes Res. 2011;2011:761950.PubMedCentralPubMedCrossRef
44.
Zurück zum Zitat Hardt P, Hammer H, Abrahamian H, Ebenbichler C, Hummel M, Matthaei S, Schnell O, Spinas G, Weitgasser R, Wiesli P, Philippe J. Diagnostik und Therapie der exokrinen Pankreasinsuffizienz bei Diabetes mellitus. Diabetes Stoffwech H. 2011;20:185–90. Hardt P, Hammer H, Abrahamian H, Ebenbichler C, Hummel M, Matthaei S, Schnell O, Spinas G, Weitgasser R, Wiesli P, Philippe J. Diagnostik und Therapie der exokrinen Pankreasinsuffizienz bei Diabetes mellitus. Diabetes Stoffwech H. 2011;20:185–90.
45.
Zurück zum Zitat Vesterhus M, Raeder H, Aurlien H, Gjesdal CG, Bredrup C, Holm PI, Molven A, Bindoff R, Berstad A, Njolstad PR. Neurological features and enzyme therapy in patients with endocrine and exocrine pancreas dysfunction due to CEL mutations. Diabetes Care. 2008;9:1738–40.CrossRef Vesterhus M, Raeder H, Aurlien H, Gjesdal CG, Bredrup C, Holm PI, Molven A, Bindoff R, Berstad A, Njolstad PR. Neurological features and enzyme therapy in patients with endocrine and exocrine pancreas dysfunction due to CEL mutations. Diabetes Care. 2008;9:1738–40.CrossRef
46.
Zurück zum Zitat Davidai G, Zakaria T, Goldstein R, Gilai A, Freier S. Hypovitaminosis E induced neuropathy in exocrine pancreatic failure. Arch Dis Childhood. 1986;61:901–3.CrossRef Davidai G, Zakaria T, Goldstein R, Gilai A, Freier S. Hypovitaminosis E induced neuropathy in exocrine pancreatic failure. Arch Dis Childhood. 1986;61:901–3.CrossRef
47.
Zurück zum Zitat Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut 2005;54(Suppl VI):vi1–vi28. Keller J, Layer P. Human pancreatic exocrine response to nutrients in health and disease. Gut 2005;54(Suppl VI):vi1–vi28.
48.
Zurück zum Zitat Hammer HF. Pancreatic exocrine insufficiency: diagnostic evaluation and replacement therapy with pancreatic enzymes. Dig Dis. 2010;28:339–43.PubMedCrossRef Hammer HF. Pancreatic exocrine insufficiency: diagnostic evaluation and replacement therapy with pancreatic enzymes. Dig Dis. 2010;28:339–43.PubMedCrossRef
49.
Zurück zum Zitat Hammer HF, Fine KD, Santa Ana CA, Porter JL, Schiller LR, Fordtran JS. Carbohydrate malabsorption: its measurement and its contribution to diarrhea. J Clin Invest. 1990;86:1936–44.PubMedCentralPubMedCrossRef Hammer HF, Fine KD, Santa Ana CA, Porter JL, Schiller LR, Fordtran JS. Carbohydrate malabsorption: its measurement and its contribution to diarrhea. J Clin Invest. 1990;86:1936–44.PubMedCentralPubMedCrossRef
50.
Zurück zum Zitat Hammer HF, Hammer J. Diarrhea caused by carbohydrate malabsorption. Gastroenterol Clin N Am. 2012;41:611–27.CrossRef Hammer HF, Hammer J. Diarrhea caused by carbohydrate malabsorption. Gastroenterol Clin N Am. 2012;41:611–27.CrossRef
Metadaten
Titel
An update on pancreatic pathophysiology (Do we have to rewrite pancreatic pathophysiology?)
verfasst von
Univ. Prof. Dr. Heinz F. Hammer
Publikationsdatum
01.02.2014
Verlag
Springer Vienna
Erschienen in
Wiener Medizinische Wochenschrift / Ausgabe 3-4/2014
Print ISSN: 0043-5341
Elektronische ISSN: 1563-258X
DOI
https://doi.org/10.1007/s10354-013-0260-y

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