Chylous ascites secondary to hyperlipidemic pancreatitis with normal serum amylase and lipase

A 54-year old man with a family history of hyperlipidemia was admitted with a 12 h history of severe generalized abdominal pain associated with nausea, vomiting and abdominal distension. Examination of the abdomen revealed tenderness in the periumblical area with shifting dullness. Serum pancreatic amylase was 29 IU/L and lipase 44 IU/L, triglyceride 36.28 mmol/L. Ultrasound showed ascites. CT of the abdomen with contrast showed inflammatory changes surrounding the pancreas consistent with acute pancreatitis. Ultrasound （US） guided abdomen paracentesis yielded a milky fluid with high triglyceride content consistent with chylous ascites. The patient was kept fasting and intravenous fluid hydration was provided. Meperidine was administered for pain relief. On the following days the patient＇s condition improved and he was gradually restarted on a low-fat diet, and fat lowering agent （gemfibrozil） was begun, 600 mg twice a day. On d 14, abdomen US was repeated and showed fluid free peritoneal cavity. The patient was discharged after 18 d of hospitalization with 600 mg gemfibrozil twice a day. At the time of discharge, the fasting triglyceride was 4.2 mmol/L. After four weeks the patient was seen in the clinic, he was well.     

血清淀粉酶和脂肪酶浓度及其比值对急性胰腺炎诊断价值的研究

目的探讨血清淀粉酶、脂肪酶浓度及脂肪酶／淀粉酶浓度比值在急性胰腺炎的病因分类和指导疾病的分级诊断中的作用。方法收集急性胰腺炎患者128例,按照病因分为胆源性、酒精性、其他病因三组,按照病情严重程度结合CT检查结果分为轻、中、重三组,比较各组间血清淀粉酶、脂肪酶浓度,脂肪酶／淀粉酶浓度比值的差异。结果酒精性急性胰腺炎患者的血清淀粉酶水平低于胆源性和其他病因患者（P=0．005、0．026）,胆源性和其他病因组间淀粉酶浓度差异无统计学意义。各病因分组之间,脂肪酶浓度和脂肪酶／淀粉酶浓度比值的差异均无统计学意义。按照疾病严重程度分组研究中,淀粉酶、脂肪酶浓度以及脂肪酶／淀粉酶浓度比值在各组间的差异无统计学意义。结论血清淀粉酶浓度在鉴别酒精性和非酒精性急性胰腺炎方面有指示作用,而脂肪酶浓度及脂肪酶／淀粉酶浓度比值不足以用来鉴别急性胰腺炎的病因,也不能单独作为指示疾病严重程度的指标。     

Specificity of increased amylase to creatinine clearance ratio in acute pancreatitis

The amylase to creatinine clearance ratio was found to be normal in 11 of 33 patients with acute pancreatitis. The ratio was elevated in 10 of 19 patients with renal insufficiency. Thus, it does not seem to be a specific index in the diagnosis of acute pancreatitis.     

Specificity of serum amylase and amylase creatinine clearance ratio in the diagnosis of acute and chronic pancreatitis.

In 31 patients with pancreatitis, the amylase to creatinine clearance ratio (CACR) was significantly greater than for controls (10.7 +/- 1.7 vs. 2.6 +/- 0.3, P less than .001). Sixteen pancreatitis patients with serum amylase (SAm) within the normal range had a mean CACR significantly greater than that of 19 hospital control patients with normal SAm (9.2 +/- 1.5 vs. 3.0 +/- 0.4, P less than .001). For control patients a highly significant inverse correlation between SAm and CACR was observed. No relationship was detected between these parameters for pancreatitis patients. The results suggest that the CACR may be of aid in establishing the diagnosis of pancreatitis even in patients without hyperamylasemia.     

Lipase/amylase ratio in biliary acute pancreatitis and alcoholic acute/acutized chronic pancreatitis

BACKGROUND: Alcoholic or biliary acute pancreatitis may need different therapeutic approaches. AIM: Assessing the validity of lipase/amylase ratio in differentiating biliary from alcoholic acute pancreatitis/acutized chronic pancreatitis. METHODS: Nine male patients (mean age and standard deviation: 39.8 +/- 7.0 years) with alcoholic acute pancreatitis/acutized chronic pancreatitis (group I) and 29 patients, 8 male and 21 female (mean age: 43.6 +/-19.9 years), with biliary acute pancreatitis (group II) were evaluated. Serum lipase and amylase levels were measured in patients with symptoms for no more than 48 hours. The lipase/amylase ratio was calculated based on serum lipase and amylase levels and expressed as multiples of their respective superior reference values. RESULTS: Mean levels of serum lipase (4,814 +/- 3,670 U/L) and amylase (1,282 +/- 777 U/L) in patients of group I were comparable to group II (2,697 +/- 2,391 and 1,878 +/- 1,319 U/L, respectively), but the mean lipase/amylase ratio was significantly higher in group I (4.4 +/- 3.6) than in group II (2.2 +/- 2.2). Lipase/amylase ratio >3 occurred at significantly higher proportions in patients of group I (66.7%) than of group II (24.1%), differentiating the two groups with sensitivity of 67% and specificity of 76%. CONCLUSIONS: 1) Amylase and lipase serum levels did not differ in the two groups evaluated; 2) the lipase/amylase ratio >3 was more often seen in alcoholic acute pancreatitis/acutized chronic pancreatitis than biliary acute pancreatitis, and it may be useful in differentiating these two causes of pancreatitis.     

轻症急性胰腺炎患者血清淀粉酶不降的原因分析及处理对策

目的 探讨轻症急性胰腺炎患者血清淀粉酶不降的原因及防治对策.方法 对我院307例轻症急性胰腺炎患者的临床资料进行回顾性分析.结果 轻症急性胰腺炎患者血清淀粉酶不降的原因主要为急性胰腺炎病因未去除、进食不当、急性胰腺炎病情进展、特殊类型急性胰腺炎及合并其他疾病等.结论 观察并分析轻症急性胰腺炎患者血清淀粉酶不降的原因,采取正确的处理对策,对轻症急性胰腺炎患者的康复至关重要.     

Prevalence of normal serum amylase levels in patients with acute alcoholic pancreatitis

Acute alcoholic pancreatitis is uncommonly diagnosed when the serum amylase level is normal. We defined acute alcoholic pancreatitis as a clinical syndrome in which hyperamylasemia was not a necessary component and sought support for the diagnosis by ultrasonography and computed tomography of the pancreas. In 68 episodes of acute alcoholic pancreatitis identified in a one-year period, the serum amylase level was normal at the time of hospital admission in 32%. In 40 episodes, we performed ultrasonography and computed tomography within 48 hr of admission. The diagnosis was supported by ultrasonography in 43%, by computed tomography in 68%. Ultrasonography and computed tomography supported the diagnosis as frequently in patients with normal serum amylase levels as in patients with hyperamylasemia. We conclude that patients with acute alcoholic pancreatitis frequently have normal serum amylase levels. The widespread clinical practice of relying solely on hyperamylasemia to establish the diagnosis of acute alcoholic pancreatitis is unjustified and should be abandoned.     

Histopathologic correlates of serum amylase activity in acute experimental pancreatitis

The association of serum amylase activity with the extent of pancreatic injury in acute pancreatitis is unclear. To clarify this relationship, we induced acute pancreatitis ranging from mild to lethal in 118 Sprague-Dawley rats (350–450 g). This was achieved by controlled intraductal infusion of low- or high-dose bile salt, with or without enterokinase, followed by intravenous cerulein or saline for 6 hr. Serum amylase was measured at baseline and 6 hr. Pancreatic histopathology was evaluated by two blinded pathologists employing total surface scoring (N=118) and morphometric 20-field documentation (N =22). Serum amylase correlated best with edema (r=0.61) and fat necrosis (r=0.58), less well with acinar necrosis (r=0.53) and inflammation (r=0.50), and poorly with hemorrhage (r=0.33) and perivascular infiltrate (r=0.31). Inasmuch as edema and fat necrosis are not important determinants of severity, these observations could explain the poor prognostic value of serum amylase activity in patients with acute pancreatitis.J. Schmidt was supported by grants from Deutsche Forschungsgemeinschaft No. Schm 781/1-1+2 and C. Fernandez-del Castillo was supported by Boehringer Foundation, Mexico.Preliminary results of this research have been presented in part at the Annual Meeting of the American Gastroenterological Association, New Orleans, May 19–22, 1991.     

急性胰腺炎患者血淀粉酶变化和CT诊断的比较

目的探讨血淀粉酶的变化规律及其机制。方法本研究对确诊的172例急性胰腺炎(AP)患者随机分为3组,分别在发病≤12 h、12～24 h、48～72 h行CT和血淀粉酶检查。分析不同时间段CT和血淀粉酶检出率。结果 87.5%患者血淀粉酶在6～12 h升高;100%患者血淀粉酶在12 h以上升高。91.3%的患者在12～24 h之间CT检查发现胰腺炎症变化,但与发病大于48 h相比,无显著差异。12 h之内,血淀粉酶升高的阳性率高于CT诊断的阳性率(χ2=22.04,P<0.01)。48～72 h D级、E级检出率明显高于12 h之内和12～24 h之间的检出率。血淀粉酶随着轻症急性胰腺炎分级水平有上升趋势;随着重症急性胰腺炎分级水平有下降趋势。结论血淀粉酶升高的水平与胰腺炎的病情程度无明显相关性,推测其机制可能与胰腺微循环受损程度有关。     

Severe acute pancreatitis and normal serum amylase activity due to pancreatic isoamylase deficiency

Summary A 31-year-old man with a primary attack of severe acute alcohol-induced pancreatitis presenting with a low to normal amylase activity in serum is described. The diagnosis was confirmed surgically and, further, by studies of immunoreactive trypsin in serum, which was elevated. Analysis of pancreatic isoamylase in serum during the convalescence showed very low activity. The patient is thought to represent a case of pancreatic isoamylase deficiency.This study was supported by grants from Syskonen Svenssons foundation for medical research.     

Sensitivity and specificity of blood amylase, amylase and creatinine clearance ratio and urinary amylase/urinary creatinine ratio in the diagnosis of acute pancreatitis

The sensitivity and specificity of amylasemia, the ratios of amylase/creatinine clearance and amylasuria/creatininuria were determined in four groups of patients: a control group (n = 43), patients with acute pancreatitis detected on computed tomography (n = 30, 25 cases of alcoholic pancreatitis), patients with an acute surgical abdomen without pancreatitis (n = 25), and patients with renal failure (n = 20). Sensitivity was defined for the acute pancreatitis group and specificity for the other groups. When amylasemia was greater than 20 UI/dl and the amylasuria/creatininuria ratio greater than 100, sensitivity was 98 per cent. The specificity of these two results in patients with an acute surgical abdomen was 98 per cent. When the ratio amylase/creatinine clearance ratio was greater than 4 sensitivity was 73 per cent and specificity in patients with acute surgical abdomen was 75 per cent. These two values were lower than those of the two preceding tests (p less than 0.01). Sensitivity of the association of an amylasemia greater than 13 UI/dl (m + 2SD) with a clearance ratio greater than 4 was 73 per cent. The amylase/creatinine clearance ratio did not seem to be reliable since its change was delayed with respect to the increase of amylasemia and amylasuria. This ratio has a poor specificity as it increased when the clearance of creatinine decreased in the group with an acute surgical abdomen associated with functional or organic renal failure. In these two groups, the correlation between the amylase/creatinine clearance ratio and creatininemia was significant. This suggested that the clearance of creatinine fell more rapidly than the clearance of amylase as renal failure increased.     

淀粉酶联合CRP和SAA检测对急性胰腺炎诊断价值的评价

目的 探讨淀粉酶、C反应蛋白(C-reactive protein,CRP)及血清淀粉样物质A(serumamyloid A,SAA)的变化对AP诊断的临床意义.方法 测定MAP和SAP患者发病24 h内、48 h、72 h及第7天的血、尿淀粉酶和CRP、SAA水平.结果 发病24 h内SAP患者的血淀粉酶、尿淀粉酶、CRP和SAA水平分别为(904.5±402.2)U/L、(2280.3±1270.3)U/L、(155.6±36.2)mg/L和(521.9±109.4)mg/L,均明显高于MAP患者的(598.3±400.4)U/L、(1304.9±868.7)U/L、(51.9 4±38.0)mg/L和(158.6±187.6)mg/L(P＜0.05或P＜0.001);血淀粉酶高峰出现于发病后24 h内,而尿淀粉酶、CRP和SAA高峰出现在发病48 h,分别为(2173.5±1110.6)U/L、(185.3±41.4)mg/L和(717.5±144.2)mg/L.MAP和SAP患者血、尿淀粉酶水平在第7天均明显降低(P＜0.05),MAP患者CRP、SAA在第7天也明显降低(P＜0.05),但SAP患者CRP、SAA在第7大无明显降低(P＞0.05).CRP、SAA和病变发展相平行,CRP和SAA呈正相关(r=0.761,P＜0.05).结论 淀粉酶联合CRP、SAA水平的检测能够早期诊断AP,CRP和SAA可作为早期诊断SAP的参考指标.     

Relation of diagnostic serum amylase levels to aetiology and severity of acute pancreatitis.

The sensitivity of diagnostic serum amylase (greater than 1000 iu/l) was assessed in 417 patients with acute pancreatitis as a result of gall stones (258), alcohol (104), or miscellaneous causes (55), of whom 111 (27%) had a clinically severe attack (including 34 deaths). On hospital admission, an amylase value diagnostic of pancreatitis was found in 96.1% of all mild cases and in 87.4% of severe cases (p less than 0.001); at 48 hours these values were 33.3% and 48.2% respectively (p = 0.026). Diagnostic amylase levels for alcoholic patients were found in 86% of mild cases on admission and in 76% of severe cases (p less than 0.001, compared with other groups). The diagnostic levels were also significantly lower at 24 hours for both the alcoholic and miscellaneous groups compared with the gall stone group (p less than 0.001). Eight of 27 (30%) patients with a serum amylase activity less than 1000 iu/l had pancreatic necrosis compared with 12 of the remaining 390 (3.1%) patients (p less than 0.001); the mortality was also significantly different (44% v 5.6% respectively, p less than 0.001). These data support the view that more sensitive tests for acute pancreatitis are needed for routine use especially in those whose disease has an alcoholic aetiology.     

The value of serum amylase and elastase measurements in the prediction of post-ERCP acute pancreatitis

BACKGROUND/AIMS: Acute pancreatitis is the most serious complication of endoscopic retrograde cholangiopancreatography (ERCP) but is not very common. A test that could predict the occurrence of pancreatitis would help to decide whether to discharge a patient after ERCP or not. The aim of this prospective study was to compare the value of serum amylase and elastase in the prediction of post-ERCP pancreatitis and its severity. METHODOLOGY: Ninety-seven patients underwent ERCP. Serum samples were taken before, two and six hours after ERCP for amylase and elastase measurement. Fifty-four patients (group A) were treated with continuous intravenous infusion of octreotide, beginning 6 hours before ERCP and terminating 24 hours after. Forty-three patients (group B) received no preventive treatment. RESULTS: In group A, 9 patients (16.6%) developed pancreatitis, 8 of them (14.8%) mild and 1 (1.8%) severe. Two patients in group B developed mild pancreatitis (p = 0.1). In all patients the predictive accuracy in the second hour for amylase >3N, >5N and elastase >N was 79%, 87% and 86% respectively. The likelihood ratio of positivity (LRP) was 3.6, 6.5 and 6.1. In the sixth hour the respective values were 76%, 86%, 85% and 4, 7.3 and 6.4. In group A, the respective values in the second hour were 85%, 91%, 94% and 5, 25.2, infinity, and in the sixth hour 85%, 94%, 98% and 5.7, 11.5, infinity. CONCLUSIONS: Serum amylase (with cutoff value >5N) and elastase (>N), 6 hours after ERCP, were the most accurate tests for the prediction of post-ERCP pancreatitis, especially in patients receiving octreotide. The measurement of serum elastase could supplement that of serum amylase in the prediction of more cases of post-ERCP pancreatitis.     

Serum amylase and lipase concentrations and lipase/amylase ratio in assessment of etiology and severity of acute pancreatitis

We studied the behavior of serum amylase and lipase in 66 consecutive patients with acute pancreatitis in order to assess the ability of these tests and of the serum lipase-amylase ratio to establish the etiology and predict the severity of acute pancreatitis. Forty-two patients had biliary acute pancreatitis, 14 had alcoholic acute pancreatitis, and the remaining 10 nonbiliary, nonalcoholic (NBNA) acute pancreatitis. Serum amylase and lipase were abnormally high in all patients. The elevations of both serum amylase and lipase were significantly lower in patients with alcoholic pancreatitis than in those with biliary pancreatitis, although a considerable overlap was observed between the two groups. No statistically significant differences were found between NBNA patients and those with either biliary or alcoholic forms of the disease. The serum lipase-amylase ratios in patients with alcoholic pancreatitis ranged from 0.2 to 5.6, in those with biliary pancreatitis from 0.1 to 7.9, and in those with NBNA pancreatitis from 0.1 to 4.4. These differences were not statistically significant. No differences in serum enzyme levels were observed among patients without apparent imaging signs of acute pancreatitis (N=20), those with signs of Pancreatic edema (N=36), and those with necrotizing pancreatitis (N=10). The results indicate that serum amylase and lipase concentrations are not able to establish either the etiology or to predict the severity of acute pancreatitis as assessed by imaging techniques. Furthermore, the serum lipase-amylase ratio is not useful in distinguishing acute episodes of alcoholic from nonalcoholic acute pancreatitis.     

血清淀粉酶监测对 ERCP 术后胰腺炎的预测

目的 探讨为预测ERCP术后急性胰腺炎或持续重度高淀粉酶血症发生而测定血清淀粉酶的最佳时间.方法 对198例行ERCP术的患者分别测定术前即刻和术后2 h、4 h、8 h、24 h的血清淀粉酶值,将2 h、4 h、8 h的血清淀粉酶值分别与24 h的血清淀粉酶值及最终临床结果 比较.结果 198例患者中15例在ERCP术后24 h的血清淀粉酶水平仍高于正常值上限的5倍( > 575 IU/L),与其他淀粉酶水平较低的患者比较,在所有时间点上淀粉酶值都有显著性差异.虽然8 h点的血清淀粉酶水平判断术后胰腺炎的敏感性最高,但考虑实用价值可将4 h点作为一可靠预测指标.结论 ERCP术后4 h血清淀粉酶水平是有利于随访、具有经济效益、预测术后胰腺炎或重度高淀粉酶血症发生的指标.