Glucagon in Acute Medicine Glucagon in Acute Medicine Pharmacological, clinical and therapeutic implications EDITED BY J. Picazo, MD '\)\.~ ~OlOr;t.,4 d!~~ .:::s ~ \C ~Q~IV ~~ #. ~~"" "'OD~ The Proceedings of an International Workshop held in Barcelona on 23 October, 1992, under the auspices of the Escuela de ţ'atologia Digestiva, Barcelona .... •• SPRINGER-SCIENCE+BUSINESS MEDIA, B.V. A catalogue record for this book is available from the British Library ISBN 978-94-010-4984-9 ISBN 978-94-011-2220-7 (eBook) DOI 10.1007/978-94-011-2220-7 Copyright © 1993 Springer Science+Business Media Dordrecht Originally published by Kluwer Academic Publishers in 1993 AII rights reserved. No part of this publication may be reproduced. stored in a retrieval system. or trasmitted in any form or by any means. electronic. mechanical. photocopying. recording or otherwise. without prior permission from the publishers. Springer-Science+Business Media, B.V. Typeset by Lasertext Ud. . Stretford. Manchester M32 OIP. Contents List of Participants vii Preface F. Vilardell ix 1 An introduction to glucagon P. ]. Lejebvre 1 2 Cardiovascular emergencies G. P. Zaloga 11 3 Glucagon for the treatment of respiratory emergencies ]. E. Wilson and P. B. Fontanarosa 27 4 Genitourinary emergencies and glucagon s. P. Ros 37 5 Glucagon for metabolic/endocrinologic emergencies: hypoglycaemia M. B. Heller and R. B. Vukmir 47 6 Acute poisoning and glucagon ]. A. Henry 67 7 Acute mesenteric ischaemia ]. L. Cronenwett 83 8 Intestinal strangulation A. Oshima and M. Kitajima 107 v GLUCAGON IN ACUTE MEDICINE 9 Glucagon in gastrointestinal radiology emergencies ]. Skucas 119 10 Glucagon for the management of hepatic emergencies A. L. Baker 131 11 Biliary and pancreatic emergencies D. L. Carr-Locke 141 Final discussion ISS From the Chairmen P. ]. Lejebvre and F. Vi/ardell 167 Index 169 vi List of Participants A. L. BAKER P. J. LEFEBVRE Liver Study Unit Diabetes, Nutrition and Metabolic Disorders University of Chicago Unit Chicago, Illinois 60637 C.H.U. Sart Tilman USA University of Liege Liege D. L. CARR-LOCKE Belgium Endoscopy Center Brigham & Women's Hospital A.OSHIMA Harvard Medical School Department of Surgery Boston, Massachusetts 02115 Tokyo Adventist Hospital USA Tokyo 167 Japan J. L. CRONENWETT Section of Vascular Surgery S. P. ROS Darmouth-Hitchcock Medical Center Department of Pediatrics Lebanon, New Hampshire 03756 Loyola University Medical Center USA Maywood, Illinois 60153 USA M. B. HELLER Division of Emergency Medicine J. SKU CAS University of Pittsburgh Department of Radiology School of Medicine University of Rochester Medical Center Pittsburgh, Pennsylvania 25213 Rochester, New York 14262 USA USA J. A. HENRY F. VILARDELL National Poisons Unit Escuela de Patologia Digestiva Guy's Hospital Universidad Aut6noma London, SE1 9RT Barcelona UK Spain vii GLUCAGON IN ACUTE MEDICINE J. E. WILSON G. P. ZALOGA Department of Emergency Medicine Department of Anesthesia and Medicine Akron City Hospital Section on Critical Care Northeastern Ohio Universities College of Bowman Gray School of Medicine Medicine Wake Forest University Akron, Ohio 44309 Winston-Salem, North Carolina 27157-1009 USA USA viii Preface The fourth international workshop on glucagon of this series (Barcelona, 1992), which focused on the use of glucagon in emergency medicine, departed from the main topic of diagnosis and treatment in hepatogastroenterology dealt with in the previous three meetings. This most recent workshop concentrated on the use of glucagon in acute, critical care medicine. The interest in glucagon as a therapeutic agent is not new. The first workshop on glucagon (Madrid, 1978) defined the physiological role of glucagon and discussed its uses in clinical gastroenterology, particularly as an aid to diagnosis in the areas of endoscopy and radiology. Also examined were the spasmolytic effects of glucagon and its value in the treatment of biliary colic, as well as the management of biliary tract disease and that of liver failure. After the first workshop, new developments occurred and research continued. The usefulness of glucagon as an aid to gastro-duodenoscopy and ERCP became well-established; assessment was undertaken on the inhibitory effects of glucagon on gastric acid; and research was done on glucagon analogues and fragments, the action of glucagon on the sphincter of Oddi, and the effect of glucagon in certain liver diseases. These advances led to the organization of a second workshop (Madrid, 1981) in which the subjects of the first workshop were treated in much more depth, and the use of glucagon in the therapy of colonic disorders, fulminant liver failure and alcoholic hepatitis was discussed. I was impressed at that time by the huge amount of literature devoted to these subjects and especially by the potential therapeutic effects of glucagon on a number of conditions. Two years later, Professor Lefebvre edited his work on the physiological and clinical features of glucagon. ix GLUCAGON IN ACUTE MEDICINE In 1987, a third workshop on glucagon took place in Barcelona. The meeting was divided in two sessions. One covered glucagon physiology, glucagon receptors, and an updating of the diagnostic and therapeutic uses of this hormone in the gastrointestinal and biliary tracts. The second session was devoted to glucagon in hepatology, particularly its hepatotrophic effects when coupled with insulin, its possible role in fulminant hepatitis, and its role in acute alcoholic liver disease. The fourth and most recent workshop, the proceedings of which are gathered in this current volume, dealt with a rather different and more complicated subject, that of glucagon in emergency medicine. Critical care medicine has become a fully recognized specialty in many countries. Whether for good or for bad, intensive care medicine is growing in importance due to the increasing application of advanced technologies to saving or prolonging lives. Emergency medicine is expected to assume an increasingly larger role, both technically and scientifically, within the field of medicine. Emergency medicine provides a new forum for the open discussion of previously unrecognized problems related to the management of a constellation of conditions arising from a common denominator-saving lives. This new field is ideal for the analysis of glucagon with its large variety of multi-targeted actions. In the following proceedings from the fourth workshop on glucagon, we examine glucagon in relation to conditions such as respiratory and cardiovascular problems, genitourinary disorders, metabolic and endocrine acute diseases, as well as acute poisoning. The gastrointestinal tract is included in presentations on the effects of glucagon on biliary acute conditions and its use in emergency gastrointestinal radiology. Given that so much is happening in the study of glucagon, the format of the workshop was particularly attractive. A distinguished group of scientists from different parts of the world participated in a working event. The program had been carefully planned to ensure that all aspects of the subject of glucagon in acute medicine were covered. A very tight schedule was drawn up for we had to treat a wide range of interrelated topics in just one day. The concentrated program permitted that an international group of highly occupied professionals could participate and share their knowledge in a multi-disciplinary framework. One of the great advantages of this context, remarked upon by more than one of the participants, was that one was drawn out of working in one's own particular field and introduced to others working in different fields only to find that they were working on similar topics. It was a pleasure for me to welcome discussants attending the workshop for the first time. Other speakers were veterans of previous workshops, ensuring a desirable continuity. This fourth meeting continued the "freedom of speech" tradition established in previous workshops as we believe that by x PREFACE far the most important aspect and contribution to the success of the workshop is the possibility of ample, relaxed and even belligerent discussion and criticism. I would like to thank most heartily all the workshop participants for their contributions and cooperation, not only during the meeting, but also before and after. Without them it would not have been possible to present and to disseminate so much information, nor would this book exist in its current form. I also extend my thanks to Dr. Jose Picazo who brilliantly organized the event and made it possible for all of us to meet. I congratulate him, Mari Carmen Hernandez and Alice Gail Bier on the publication of this book, for it was they who had to gather the manuscripts together from different corners of the world and pull our far-ranging discussions into shape. Finally, I would like to thank our publishers for working so professionally and cooperatively to produce this book. In short, to everyone involved I extend my thanks for their contributions to what was a most interesting and worth while project. Barcelona F. VlLARDELL June, 1993 Address for correspondence: Prof. D. Francisco Vilardell Director Escuela de Patologia Digestiva Hospital San Pablo Avda. S. Antonia Ma Claret 167 08025 BARCELONA Spain xi