Acute pancreatitis

What is the best biochemical test to diagnose acute pancreatitis? A prospective clinical study

OBJECTIVE

To determine which biochemical test is best to distinguish acute pancreatitis from other pancreatic and nonpancreatic diseases associated with hyperamylasemia.

DESIGN

We conducted a prospective clinical study of 836 consecutive patients who had a total serum amylase test requested by a physician during a 7-month period.

MATERIAL AND METHODS

Radioimmunoassay and enzymatic activity methods were used to measure pancreas-specific proteins of varied size, charge, and stability. In addition, scoring systems were used for the diagnosis of pancreatitis, and statistical analyses were done to determine sensitivity and specificity.

RESULTS

We found minor differences in sensitivity and specificity for diagnosis of acute pancreatitis among pancreatic isoamylase, phospholipase A2, colipase, lipase, and carboxylester lipase. Of these tests, the combination of isoamylase and phospholipase A2 had a small but statistically significant increased sensitivity (90%; 95% confidence interval [CI] = 74 to 98%) and specificity (93%; 95% CI = 91 to 95%) over isoamylase (90% and 92%, respectively; 95% CI = 90 to 94%) and phospholipase A2 (90% and 75%, respectively; 95% CI = 72 to 78%) alone for the diagnosis of acute pancreatitis.

CONCLUSION

Pancreas-specific proteins are satisfactory for diagnosing acute pancreatitis if the test is validated by the laboratory. Clinically, the slight advantage of using both isoamylase and phospholipase A2 does not outweigh the expense of performing two assays; we recommend using isoamylase to diagnose acute pancreatitis.

Acute pancreatitis: the role of early surgery

Conservative treatment for an attack of acute pancreatitis still takes priority. The treatment of choice in biliary pancreatitis is endoscopic papillotomy with extraction of any bile duct stones. After this procedure the patient usually recovers quickly and cholecystectomy should be done as an interval operation. An early operation has to be done when conservative treatment fails and organ failure occurs. The 'gold standard' of surgical therapy today is the opening of the lesser sac with continuous postoperative lavage and drainage, digital elimination of necrotic tissue and drainage of the paracolic areas. Other described surgical procedures do not produce significantly better results. Necrotizing pancreatitis still has a high mortality in contrast to mild oedematous pancreatitis, which is rarely a problem.

Acute pancreatitis following aortic aneurysm repair: report of three cases

This paper reports three cases of acute pancreatitis that occurred after repair of an abdominal aortic aneurysm. The aneurysms were ruptured in two patients and asymptomatic in one. No patient had biliary disease or history of pancreatitis or alcohol abuse. Two of the patients required operation for drainage and debridement; one died. The etiology and diagnosis are discussed.

Gallstone pancreatitis

Gallstone pancreatitis is caused by transient obstruction of the ampulla of Vater by a migrating gallstone. Intraglandular activation of pancreatic enzymes occurs (by an unclear mechanism), and their entry into the circulation causes most of the local and systemic events of pancreatitis. The diagnosis is based on history and physical examination, an elevation of serum amylase above 1000 IU/L, and ultrasound and CT scans. Endoscopic retrograde cholangiopancreatography can be used in less certain cases to confirm the presence of common bile duct stones. Because of the absence of an agent that can abort progression of the disease, therapy should consist of adequate resuscitation, nutritional support, and careful monitoring to detect early complications. In patients with mild pancreatitis, surgery usually can be performed within 48 or 72 hours of admission or as soon as symptoms and amylase levels return to normal. For patients with severe disease, endoscopic sphincterotomy is emerging as the therapeutic modality of choice. Elective treatment of the associated biliary disease should be performed during the same hospitalization after the acute phase of the disease has subsided.

A case of leiomyosarcoma associated with humoral hypercalcemia of malignancy: demonstration of biological and immunological activities of parathyroid hormone-related protein in the tumor extract

Hypercalcemia occurred in a patient with leiomyosarcoma when multiple lung metastases developed. Despite normal plasma parathyroid hormone (PTH) levels and low 1,25-dihydroxyvitamin D, this hypercalcemic patient had a marked hypercalciuria and phosphaturia associated with an increased excretion of nephrogenous cyclic AMP (NcAMP). Administration of cisplatin ameliorated both the hypercalcemia and hypercalciuria without any reduction in tumor size of NcAMP excretion. Terminally, acute pancreatitis occurred producing a profound hypocalcemia. In the extract of tumor tissue obtained post mortem, bioactivity stimulating the generation of cyclic AMP in osteogenic cells was demonstrated along with the immunoreactive PTH-related protein (PTH-rP). the first report of a solid non-epithelial malignancy producing PTH-rP and associated with humoral hypercalcemia of malignancy. The hypercalcemia in this case caused acute pancreatitis, which led to a profound hypocalcemia.