Familial pancreatic hyperenzymemia

Long-term outcomes and adverse effects of teduglutide in patients with short bowel syndrome: Highlighting hyperamylasemia and hyperlipasemia

PURPOSE

Short bowel syndrome is a malabsorptive condition that occurs due to surgical removal or a congenital absence of a significant portion of the small intestine. Patients with short bowel syndrome often rely on parenteral support for extended periods or even their entire lives. Teduglutide, a glucagon-like peptide-2 analog, has shown promising results in reducing dependency on parenteral support in these patients by promoting intestinal adaptation and enhancing nutrient absorption. However, the long-term safety of teduglutide remains a concern, particularly with respect to its potential for the development of hyperamylasemia and hyperlipasemia.

METHODS

This study involved patients who received teduglutide from December 2012 to December 2022 at Boston Medical Center. We evaluated outcomes and adverse events, focusing on hyperamylasemia and hyperlipasemia, through chart review.

RESULTS

Thirteen eligible patients were identified who had used teduglutide. Of these, the majority (84.6%) experienced a reduction in parenteral support. A high incidence (72.7%) of nonpathological pancreatic enzyme elevation was observed in patients treated with teduglutide. These elevations were often dose dependent and were not associated with any clinical signs of acute pancreatitis or abnormal imaging findings.

CONCLUSION

This study highlights the need for further investigations into the long-term safety of teduglutide and the importance of closely monitoring amylase and lipase levels in patients undergoing treatment with teduglutide.

Superfluous Amylase/Lipase Testing at a University-Affiliated Teaching Hospital: A Retrospective Review

Background: The combination of amylase and lipase tests for diagnosing acute pancreatitis is not better than a lipase test alone; however, both tests are commonly ordered simultaneously. Further, although no data indicate usefulness of monitoring changes in elevated amylase and lipase levels, the tests are often ordered multiple times during the same clinical encounter. Methods: We retrospectively reviewed all amylase and lipase tests performed at a university-affiliated teaching hospital during a 6-month period. We considered amylase and lipase results diagnostic if they were >3 times the upper limit of normal and borderline if they were ≤3 times the upper limit of normal. During a single clinical encounter, we considered amylase tests superfluous if ordered simultaneously with lipase tests or repeated after diagnostic results, questionably superfluous if repeated alone, and nonsuperfluous otherwise. Lipase tests were considered superfluous if repeated after diagnostic results, questionably superfluous if repeated after nondiagnostic results, and nonsuperfluous otherwise. Results: In this study, 3,502 patients had 8,801 tests (4,926 lipase, 3,875 amylase), 4% of which were diagnostic and 10% borderline. Of the 8,801 tests, 45% were superfluous and 9% were questionably superfluous. Nonsuperfluous testing was less frequent (P<0.0001) in the intensive care/stepdown units (22% of 748 tests) than in the emergency department (54% of 6,000 tests) or other settings (31% of 2,053 tests). Among 3,545 simultaneous amylase/lipase tests with nondiagnostic lipase results, 0.6% amylase results were diagnostic. Of the 190 lipase tests repeated after nondiagnostic lipase results, 12% were diagnostic. Conclusion: Superfluous amylase/lipase testing in one teaching hospital is substantial, suggesting significant potential for reducing healthcare costs without compromising the quality of care when evaluating patients for acute pancreatitis.

Endoscopic Ultrasonography May Select Subjects Having Asymptomatic Chronic Pancreatic Hyperenzymemia Who Require a Stricter Follow-up

OBJECTIVES

We have previously shown that at least 50% of patients with asymptomatic chronic pancreatic hyperenzymemia (ACPH) may develop morphological pancreatic alterations. Endoscopic ultrasonography (EUS) may detect small lesions, and its sensitivity seems to be higher than other imaging techniques. The aim of this study was to evaluate whether EUS may modify the management of patients having ACPH.

METHODS

In 2 referral centers for pancreatic disease, a retrospective analysis of prospectively enrolled patients with ACPH was conducted.

RESULTS

Seventy-three patients with ACPH were enrolled for the purpose of this study. Endoscopic ultrasonography was performed as the last examination in 45 subjects who resulted negative at previous imaging studies (abdominal ultrasound, computed tomography, magnetic resonance imaging associated with cholangiopancreatography). Using EUS in 7 subjects, abnormalities were found in the following: 3 branch-duct intraductal papillary mucinous neoplasms, 1 duodenal diverticulum, 1 annular pancreas, 1 findings suggestive of chronic pancreatitis, and 1 undefined cyst (<5 mm).

CONCLUSIONS

Endoscopic ultrasonography is able to detect alteration not found by other imaging technique in 15.5% of patients with ACPH and may be useful to select those patients who require a more strict follow-up.

Pancreatic morpho-functional imaging as a diagnostic approach for chronic asymptomatic pancreatic hyperenzymemia

BACKGROUND

Magnetic resonance cholangio-pancreatography (MRCP) findings in people with chronic asymptomatic pancreatic hyperenzymemia (CAPH) have shifted the hypothesis that CAPH is always non-pathological. However, there have been no studies including both secretin-MRCP (S-MRCP) and endoscopic ultrasonography (EUS) to examine the pancreatic morphology in these subjects.

AIM

To prospectively assess the diagnostic approach for CAPH using both pancreatic EUS and S-MRCP.

METHODS

In a case-control prospective study from January 2010 to December 2014, 68 consecutive subjects with CAPH were scheduled to undergo S-MRCP and EUS (CAPH group) in a tertiary care setting. In the same period, the EUS findings of this group were compared with 68 patients examined by EUS alone for submucosal lesions of the gastric fundus, matched for sex and age (control group).

RESULTS

EUS detected pancreatic alterations in 60.3% of the CAPH group and 13.2% of controls (p<0.001). S-MRCP showed pancreatic alterations in 51.5% in the CAPH group. With the combined procedures, pancreatic abnormalities were detected in 63.3%. The diagnoses established by the two techniques were concordant in 51 (75%) of the 68 CAPH subjects; in the remaining 17 (25%) the two methods gave additional information.

CONCLUSIONS

In people with CAPH S-MRCP and EUS are both recommended in order to detect pancreatic abnormalities before this biochemical alteration is confirmed as benign CAPH, or Gullo's syndrome.

Gullo's Syndrome: A Case Report

Benign Pancreatic Hyperenzymemia (BPH) or Gullo's Syndrome is a new entity with only few reported cases till date. It is characterized by persistently elevated pancreatic enzymes without any clinical or pathological evidence of pancreatic disease. Gullo's syndrome is a diagnosis of exclusion and clinician should be aware of various other conditions which can cause elevation of pancreatic enzymes. There are no reported cases of Gullo's syndrome from Indian subcontinent till date. A 42-year-old lady presented to us with complaints of fever and cough for which she was evaluated and diagnosed to be having left upper zone pneumonia. However, her routine investigations showed persistently elevated serum amylase and lipase levels. She was extensively worked up for pancreatic hyperenzymemia but no pancreatic disease was detected. She was followed up for a period of one year and raised levels of serum lipase and amylase persisted even after a year.

Fucosyltransferase 2 (FUT2) non-secretor status and blood group B are associated with elevated serum lipase activity in asymptomatic subjects, and an increased risk for chronic pancreatitis: a genetic association study

OBJECTIVE

Serum lipase activities above the threefold upper reference limit indicate acute pancreatitis. We investigated whether high lipase activity-within the reference range and in the absence of pancreatitis-are associated with genetic single nucleotide polymorphisms (SNP), and whether these identified SNPs are also associated with clinical pancreatitis.

METHODS

Genome-wide association studies (GWAS) on phenotypes 'serum lipase activity' and 'high serum lipase activity' were conducted including 3966 German volunteers from the population-based Study-of-Health-in-Pomerania (SHIP). Lead SNPs associated on a genome-wide significance level were replicated in two cohorts, 1444 blood donors and 1042 pancreatitis patients.

RESULTS

Initial discovery GWAS detected SNPs within or near genes encoding the ABO blood group specifying transferases A/B (ABO), Fucosyltransferase-2 (FUT2), and Chymotrypsinogen-B2 (CTRB2), to be significantly associated with lipase activity levels in asymptomatic subjects. Replication analyses in blood donors confirmed the association of FUT-2 non-secretor status (OR=1.49; p=0.012) and ABO blood-type-B (OR=2.48; p=7.29×10(-8)) with high lipase activity levels. In pancreatitis patients, significant associations were found for FUT-2 non-secretor status (OR=1.53; p=8.56×10(-4)) and ABO-B (OR=1.69, p=1.0×10(-4)) with chronic pancreatitis, but not with acute pancreatitis. Conversely, carriers of blood group O were less frequently affected by chronic pancreatitis (OR=0.62; p=1.22×10(-05)) and less likely to have high lipase activity levels (OR=0.59; p=8.14×10(-05)).

CONCLUSIONS

These are the first results indicating that ABO blood type-B as well as FUT2 non-secretor status are common population-wide risk factors for developing chronic pancreatitis. They also imply that, even within the reference range, elevated lipase activities may indicate subclinical pancreatic injury in asymptomatic subjects.

Significant elevations of serum lipase not caused by pancreatitis: a systematic review

BACKGROUND

Many authors advocate lipase as the preferred serological test for the diagnosis of pancreatitis and a cut-off level of three or more times the upper limit of normal (ULN) is often quoted. The literature contains no systematic review that explores alternative causes of a lipase level over three times as high as the ULN. Such a review was therefore the objective of this study.

METHODS

The EMBASE and MEDLINE databases (1985 to August 2013) were searched for all eligible articles. Predetermined data were extracted and independently analysed by two reviewers.

RESULTS

In total, data from 58 studies were included in the final analysis. The following causes other than pancreatitis of lipase levels exceeding three times the ULN were found: reduced clearance of lipase caused by renal impairment or macrolipase formation; other hepatobiliary, gastroduodenal, intestinal and neoplastic causes; critical illness, including neurosurgical pathology; alternative pancreatic diagnoses, such as non-pathological pancreatic hyperenzymaemia, and miscellaneous causes such as diabetes, drugs and infections.

CONCLUSIONS

A series of differential diagnoses for significant serum lipase elevations (i.e. exceeding three times the ULN) has been provided by this study. Clinicians should utilize this knowledge in the interpretation and management of patients who have lipase levels over three times as high as the ULN, remaining vigilant for an alternative diagnosis to pancreatitis. The medical officer should be aware of the possibility of incorrect diagnosis in the asymptomatic patient.

A 5-year experience of benign pancreatic hyperenzymemia

OBJECTIVE

Benign pancreatic hyperenzymemia is characterized by a long-term increase of serum pancreatic enzymes in otherwise healthy subjects. This study was designed to determine (a) whether all pancreatic enzymes are elevated, (b) the extent of each enzyme increase, (c) the relative frequency of the familial form, and (d) the relative frequencies of pancreatic and salivary hyperamylasemia and macroamylasemia.

METHODS

Two hundred seven asymptomatic subjects with benign pancreatic hyperenzymemia were studied during the 5-year period. Serum amylase, isoamylase, and lipase levels were assessed by immunoenzymatic assays.

RESULTS

Most (n = 183; 88.4%) patients had benign pancreatic hyperenzymemia; 155 (74.9%) patients had an abnormal increase of all 3 enzymes, 15 (7.2%) patients of only lipase, and 13 (6.3%) patients of only amylase and pancreatic isoamylase. Lipase levels were the highest (1.1-21 times above upper limit). Of the 183 subjects, 72 were members of 35 different families, 15 (7.2%) had increased salivary amylase, and 9 (4.3%) had macroamylasemia. Wide day-to-day fluctuations of pancreatic enzymes, including falls within the reference ranges, were recorded.

CONCLUSIONS

All enzymes were increased in benign pancreatic hyperenzymemia, with lipase showing the highest elevation. Doctors should reassure patients about the benign nature of this condition and limit repeating useless examinations.

Prospective evaluation of subjects with chronic asymptomatic pancreatic hyperenzymemia

OBJECTIVES

Chronic asymptomatic pancreatic hyperenzymemia (CAPH) has been described since 1996 as a benign disease. Recent studies described pathological findings at magnetic resonance cholangiopancreatography with secretin stimulation (s-MRCP) in more than half of the CAPH subjects. The aim of this study was to investigate the frequency and clinical relevance of s-MRCP findings in patients with CAPH.

METHODS

Subjects prospectively enrolled from January 2005 to December 2010 underwent s-MRCP and biochemical tests routinely performed.

RESULTS

Data relative to 160 subjects (94 males, 66 females, age 49.6±13.6 years) were analyzed. In all, 51 (32%) subjects had hyperamylasemia, 9 (6%) hyperlipasemia, and 100 (62%) an increase in both enzyme levels. The time between the first increased dosage of serum pancreatic enzymes and our observation was 3.3±3.9 years (range: 1-15). Familial pancreatic hyperenzymemia was observed in 26 out of 133 subjects (19.5%). Anatomic abnormalities of the pancreatic duct system at s-MRCP were found in 24 out of 160 subjects (15%). Pathological MRCP findings were present in 44 subjects (27.5%) before and in 80 subjects (50%) after secretin administration (P<0.0001). Five subjects (3.1%) underwent surgery, 3 for pancreatic endocrine tumor, 1 for pancreatic adenocarcinoma, and 1 for intraductal papillary-mucinous neoplasia (IPMN) involving the main pancreatic duct, and 18 patients (11.3%) needed a follow-up (17 for IPMN and 1 for endocrine tumor).

CONCLUSIONS

Alterations of the pancreatic duct system at s-MRCP in subjects with CAPH can be observed in 50% of the subjects and are clinically relevant in 14.4% of cases.

Chronic pancreatitis

PURPOSE OF REVIEW

We review important new clinical observations in chronic pancreatitis made in the past year.

RECENT FINDINGS

Tropical pancreatitis associates with SPINK1 and/or CFTR gene mutations in approximately 50% of patients, similar to the frequency in idiopathic chronic pancreatitis. Corticosteroids increase secretin-stimulated pancreatic bicarbonate concentrations in autoimmune pancreatitis (AIP) by restoring mislocalized CFTR protein to the apical ductal membrane. Most patients with asymptomatic hyperenzymemia have pancreatic lesions of unclear significance or no pancreatic lesions. Common pitfalls in the use of diagnostic tests for exocrine pancreatic insufficiency (EPI) confound interpretation of findings in irritable bowel syndrome and severe renal insufficiency. Further study is needed to improve the accuracy of endoscopic ultrasonography (EUS) to diagnose chronic pancreatitis. Celiac plexus block provides short-term pain relief in a subset of patients.

SUMMARY

Results of this year's investigations further elucidated the genetic associations of tropical pancreatitis, a reversible mislocalization of ductal CFTR in AIP, the association of asymptomatic pancreatic hyperenzymemia with pancreatic disorders, limitations of diagnostic tests for EPI, diagnosis of chronic pancreatitis by EUS and endoscopic pancreatic function testing and treatment of pain.

Chronic asymptomatic hyperamylasemia unrelated to pancreatic diseases

PURPOSE

This study was addressed to assess the clinical characteristics of patients presenting with chronic hyperamylasemia unrelated to pancreatic diseases (CHUPD). Almost all patients presenting with chronic hyperamylasemia undergo expensive, long, difficult, and often unnecessarily repeated diagnostic procedures. This is in conjunction with the poor knowledge of the fact that besides hyperenzymemia secondary to pancreatic diseases and systemic illnesses, various non-pathological forms of chronic hyperamylasemia without relevant pathologic consequence can occur in clinical practice.

MATERIAL AND METHODS

Data of all patients with CHUPD were retrospectively reviewed (June 1997-December 2009). Fifty one patients were included in the study; median follow up was 48 months (range 8-112 months). Their pre-enrolment diagnoses were: chronic pancreatitis in 31 cases (60.7%) and recurrent pancreatitis in 13 cases (25.4%); the remaining 7 patients (13.7%) were without a specific diagnosis.

RESULTS

Our observations, supported by diagnostic procedures (Ca19-9 serum levels, abdominal ultrasonography, computed tomography and magnetic resonance, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography) revealed that CHUPD was secondary to: a) benign pancreatic hyperamylasemia, 20 patients (39.2%); b) macroamylasemia, 18 patients (35.2 %) and c) salivary hyperamylasemia, 13 patients (25.4%).

CONCLUSIONS

Due to the poor familiarity with CHUPD, the occurrence of this condition quite frequently leads to unnecessarily repeated diagnostic procedures.

Chronic pancreatitis

PURPOSE OF REVIEW

We review important new clinical observations in chronic pancreatitis made in the past year.

RECENT FINDINGS

Cigarette smoking is a dose-dependent risk factor for acute pancreatitis, recurrent acute pancreatitis, and chronic pancreatitis. A minority of chronic alcohol consumers develop recurrent acute pancreatitis but very heavy drinking associates with chronic pancreatitis. More patients with alcohol-induced chronic pancreatitis have cirrhosis than patients with cirrhosis have chronic pancreatitis (39 vs. 18%). Most patients with asymptomatic hyperenzymemia have no pancreatic lesions. Pancreatic calcifications are most frequently due to chronic pancreatitis, followed by cystic neoplasms and other disorders. The new Rosemont consensus classification of endoscopic ultrasonography criteria for chronic pancreatitis is unvalidated. Zinc deficiency correlates only with severe chronic pancreatitis and the fecal elastase test is an inaccurate marker of pancreatic steatorrhea. Patients commonly receive insufficient lipase to abolish pancreatic steatorrhea. Ultrastructural neuropathies are common to chronic pancreatitis and pancreatic cancer and correlate with pain severity.

SUMMARY

Results of this year's investigations further elucidated risk factors for pancreatic disease, the natural history of alcoholic pancreatitis, the differential diagnosis of pancreatic calcifications, the diagnosis of chronic pancreatitis with the Rosemont criteria, the limited diagnostic utility of fecal elastate test and zinc measurements, the proper dosing of pancreatic enzyme supplements, and treatment of pancreatic pain.

Chronic asymptomatic pancreatic hyperenzymemia is a benign condition in only half of the cases: a prospective study

OBJECTIVE

Prospectively to evaluate patients with chronic asymptomatic pancreatic hyperenzymemia in order to identify possible pancreatic and non-pancreatic diseases.

MATERIAL AND METHODS

Seventy-five asymptomatic subjects with long-standing pancreatic hyperenzymemia (45 M, 30 F; mean age+/-SD 51.5+/-16.0 years, range 19-78 years, mean duration+/-SD of pancreatic hyperenzymemia 14.7+/-7.0 months, range 7-34 months) and normal ultrasonographic evaluation were included in this study. The subjects enrolled were carefully interviewed and prospectively evaluated. All patients underwent blood screening. An additional abdominal ultrasound was also carried out and, if considered necessary, other imaging and endoscopic evaluation procedures were used.

RESULTS

The follow-up of the patients after enrollment in the study was 3.3+/-1.8 years (mean+/-SD). In 38 patients (50.7%), pancreatic or extrapancreatic disease was diagnosed: 20 patients had chronic pancreatitis, 1 had autoimmune chronic pancreatitis, 1 had a benign cyst of the pancreas, 2 had serous cystadenomas, 5 had an intraductal papillary mucinous tumor of the pancreas, 3 had a ductal pancreatic adenocarcinoma, 4 patients had chronic viral hepatitis, and 2 had Crohn's disease. In 37 subjects (49.3%), no pancreatic or extrapancreatic diseases were found (3 subjects had macroamylasemia, 3 had familial hyperenzymemia, 31 had chronic non-pathological pancreatic hyperenzymemia).

CONCLUSIONS

Subjects having an increase of either amylase or lipase serum levels should undergo a thorough diagnostic work-up prior to establishing the existence of chronic non-pathological pancreatic hyperenzymemia.

Pancreatic ductal abnormalities documented by secretin-enhanced MRCP in asymptomatic subjects with chronic pancreatic hyperenzymemia

OBJECTIVES

Persistently high serum pancreatic enzymes in asymptomatic subjects are considered a benign idiopathic condition called "non-pathological chronic pancreatic hyperenzymemia" (CPH). However, recent studies with advanced imaging techniques have brought to light abnormal pancreatic findings in a significant proportion of these subjects. The objective of this study was to evaluate pancreatic ductal morphology by secretin-enhanced magnetic resonance cholangiopancreatography (MRCP-S) in subjects with CPH and compare MRCP imaging before and after secretin injection.

METHODS

In total, 25 consecutive patients with CPH were investigated by MRCP and MRCP-S and compared with 28 consecutive age-matched controls with recurrent upper abdominal pain and normal pancreatic enzymemia.

RESULTS

MRCP-S showed abnormal pancreatic morphological findings in 13 of the 25 CPH cases (52%) and 1/28 controls (3.6%) (P<0.001). MRCP findings consistent with a diagnosis of chronic pancreatitis, according to the Cambridge classification, were detected in eight CPH cases (32%) after secretin injection but none of the controls. Secretin stimulation boosted the diagnostic yield of MRCP for the diagnosis of chronic pancreatitis fourfold. Pancreas divisum was identified in two CPH cases and one control. A 15-min persisting dilation of the main pancreatic duct was noted in three cases in each group. Compared with MRCP, MRCP-S showed significantly fewer CPH patients with normal findings (P<0.02).

CONCLUSIONS

MRCP-S detected ductal findings consistent with chronic pancreatitis in one-third of CPH cases. Pancreas divisum and some dysfunction at the level of Vater's papilla were reported in 8 and 12% of the patients, respectively. MRCP-S is to be recommended, instead of MRCP, in the diagnostic work-up of CPH subjects.

Hyperamylasaemia and/or hyperlipasaemia: incidence and underlying causes in hospitalized patients with non-pancreatic diseases

OBJECTIVE

There are no recommendations on how to proceed in patients with increased pancreatic enzyme activities but non-pancreatic diseases. The objective of this study was to investigate prospectively in a general medical hospital the incidence, causes and clinical impact of hyperamylasaemia and/or hyperlipasaemia in these patients.

MATERIAL AND METHODS

During a 4-month period in 2004, amylase and lipase activities were measured in all patients (n, 1765) admitted to the Department of Internal Medicine of the Municipal Clinic of Lüneburg, Germany. Patients with increased enzyme activities underwent abdominal ultrasonography and, if inconclusive, other imaging procedures.

RESULTS

Amylase and/or lipase activities were increased in 140 (8%) patients with non-pancreatic diseases: amylase in 29 cases (21%) and 1 case (1%)<3 and>3 times the upper limit of normal, respectively, lipase in 120 cases (86%) and 6 cases (4%)<3 and>3 times, respectively. In 53 (38%) patients no further imaging studies could be performed. In the remaining 87 patients amylase was increased in 18 patients (21%) and lipase in 3 patients (3%). The pancreas was normal on imaging procedures in 77 (89%) patients and abnormal in 10 (11%) (chronic pancreatitis: 4, small cystic lesions: 6). The cystic lesions were mostly located in the pancreas head, probably corresponding to branch-duct intraductal papillary mucinous neoplasm.

CONCLUSIONS

Increased pancreatic enzyme activities occur in 8% of hospitalized patients with non-pancreatic diseases, but pancreatic abnormalities will be found in only a few (11%), which are unlikely to need further investigation or therapy. Therefore, routine analysis of amylase or lipase activities in patients with non-pancreatic diseases is not indicated.

Magnetic resonance cholangiopancreatography in asymptomatic pancreatic hyperenzymemia

OBJECTIVES

To determine the type and frequency of pancreatic lesions detected by magnetic resonance cholangiopancreatography (MRCP) in subjects with asymptomatic pancreatic hyperenzymemia and to assess for a possible relationship between these lesions and the hyperenzymemia.

METHODS

From January 2005 to May 2008, 63 subjects with asymptomatic pancreatic hyperenzymemia were studied by MRCP. In addition, amylase, pancreatic isoamylase, and lipase were determined for 5 consecutive days.

RESULTS

In most subjects (n = 57, 90.5%), MRCP showed a normal pancreas. In the remaining 6 subjects (9.5%), the following alterations were found: pancreas divisum in 2, small intrapancreatic cyst in 2, anatomic variant of the Wirsung in 1, and mild dilatation of 3 secondary ducts in 1. In these 6 subjects, hyperenzymemia was highly variable from day to day, with frequent normalizations, as was also true for the 30 subjects with no MRCP alterations in whom diurnal enzyme determinations were made.

CONCLUSIONS

Most of the subjects with asymptomatic pancreatic hyperenzymemia did not have pancreatic lesions detectable by MRCP. In the few subjects in whom a lesion was found, the great variability and the frequent transient normalization of serum enzyme levels tend to exclude a relation between the lesion and the hyperenzymemia.

Prevalence and determinants of increased serum lipase levels in a general population

OBJECTIVES

There is little information on the prevalence of increased serum lipase levels and its determinants from population-based studies. The present study was performed to provide such information.

METHODS

We used data from the 4275 subjects aged 20 to 79 years who were recruited for the population-based Study of Health in Pomerania. Serum lipase levels were determined colorimetrically; levels > or =3.17 micromol/s x l were considered increased.

RESULTS

The prevalence of increased serum lipase levels was 3.4%. The prevalence of self-reported chronic pancreatitis in this population was 0.7%. Subjects with and without increased serum lipase levels did not differ with respect to symptoms indicative of pancreatitis including abdominal feeling of fullness, abdominal pain, nausea, and loss of weight. High serum lipase levels correlated with advanced age, increased serum creatinine levels, and use of steroids or enalapril.

CONCLUSIONS

Increased serum lipase levels are unrelated to pancreatitis-related symptoms. Renal insufficiency and prevalent pancreatitis explain increased serum lipase levels in a minority of subjects. In clinical practice, drugs including steroids and enalapril should be excluded as cause of increased serum lipase levels. The predictive roleof lipase measurements with respect to other pancreatic or extrapancreatic disorders has to be investigated in cohort studies.

Benign pancreatic hyperenzymemia or Gullo's syndrome

Benign pancreatic hyperenzymemia is a newly identified syndrome characterized by an abnormal increase in serum pancreatic enzymes in the absence of pancreatic disease. The hyperenzymemia can occur sporadically or in a familial form, and all of the pancreatic enzymes show elevations. Although the condition is persistent, the enzyme elevations fluctuate considerably, even temporarily returning to normal levels at times. In this review the main characteristics of this syndrome are described.

SPINK1 and PRSS1 mutations in benign pancreatic hyperenzymemia

The aim of this study was to determine whether mutations in SPINK1/PRSS1 genes are associated with benign pancreatic hyperenzymemia (BPH).

METHODS

Sixty-eight subjects with BPH (including 13 familial cases) were studied. In all, we sequenced germline DNA for all the exons and intro-exon boundaries of PRSS1 and SPINK1.

RESULTS

Nine (13.2%) of the 68 subjects harbored PRSS1 or SPINK1 mutations. As to PRSS1, no hereditary pancreatitis-associated variant was detected, whereas previously undescribed mutations (p.Ala148Val and c.40+1G>A) were respectively found in 2 subjects (2.9%). SPINK1 mutations were detected in 7 subjects (10.3%). Five of them exhibited known mutations (3 p.Asn34Ser, 1 p.Pro55Ser, and 1 c.88-23A>T), whereas 2 had a newly found variant (p.Arg67Gly and c.*32C>T, respectively). Only 2 familial BPH, belonging to 2 different families, were found to carry a mutation (1 with p.Ala148Val for PRSS1 and 1 with p.Asn34Ser for SPINK1).

CONCLUSIONS

No known mutations of PRSS1 have been found in BPH, whereas the frequency of known SPINK1 variants is similar to that reported in the general population. No segregation of PRSS1/SPINK1 variants occurs in BPH families. Benign pancreatic hyperenzymemia cannot be explained by mutations in genes whose variants are known to be associated with pancreatitis or by mutations in other PRSS1/SPINK1 genes.

Fecal calprotectin and elastase 1 determinations in patients with pancreatic diseases: a possible link between pancreatic insufficiency and intestinal inflammation

BACKGROUND

Fecal calprotectin determination has been demonstrated to be useful in diagnosing various inflammatory diseases of the gastrointestinal tract; however, data available for patients with pancreatic diseases are scarce. Our aim was to assess fecal calprotectin in order to evaluate the presence of intestinal inflammation in patients with pancreatic disease.

METHODS

Eligible patients with suspected pancreatic illness were enrolled, and in all of them fecal calprotectin and elastase-1, as well as serum amylase and lipase activities, were assayed using commercially available kits.

RESULTS

A total of 90 subjects (47 men, 43 women, mean age 58.6 +/- 14.9 years) were enrolled: 20 (22.2%) had chronic pancreatitis; 15 (16.7%) had pancreatic cancer; six (6.7%) had chronic nonpathological pancreatic hyperenzymemia; 16 (17.8%) had nonpancreatic diseases; and 23 (25.6%) had no detectable diseases. Diarrhea was present in 19 patients (21.1%). In univariate analyses, the presence of diarrhea and low fecal elastase-1 concentrations were significantly associated (P = 0.019 and P = 0.002, respectively) with abnormally high fecal calprotectin concentration, and the multivariate analysis demonstrated that low fecal elastase-1 concentration was the only variable independently associated with a high fecal calprotectin concentration.

CONCLUSIONS

Pancreatic insufficiency may cause intestinal inflammation, probably because of a modification of the intestinal ecology.

Benign pancreatic hyperenzymemia

Benign pancreatic hyperenzymemia is a newly identified syndrome characterized by an abnormal increase in serum pancreatic enzymes in the absence of pancreatic disease. The hyperenzymemia can occur sporadically or in a familial form, and all of the pancreatic enzymes show elevations. Although the condition is persistent, the enzyme elevations fluctuate considerably, even temporarily returning to normal levels at times. In this review the main characteristics of this syndrome are described.

Benign pancreatic hyperenzymemia in children

One of us recently described chronic pancreatic hyperenzymemia in the absence of pancreatic or other disease in adult subjects. The aim of the present study was to describe this form of pancreatic hyperenzymemia in children. The study involved 15 children with this condition seen from September 1996 to December 2004. After initial evaluation, each child was seen by us once annually until the end of the study. Each check-up included serum amylase (normal values 20-220 IU/L), pancreatic isoamylase (17-115 IU/L) and lipase (24-270 IU/L) determinations as well as abdominal ultrasound. In six children, fecal elastase was also determined. At the initial assessment, 13 of the 15 children had abnormal serum increases in all three enzymes, one showed an increase only in lipase, and in the remaining child all three enzymes were present in normal concentrations. These latter two children had had abnormally elevated levels of all enzymes at the examination performed before this study began. During follow-up, enzyme concentrations remained abnormally elevated, although with wide fluctuations and transient normalizations. Considering the highest values of enzymes found in the various examinations performed during this study, the increase over the upper normal limit was in the range of 1.5- to 5.2-fold for amylase, 2.2-to 8.0-fold for pancreatic isoamylase, and 2.0- to 15.4-fold for lipase. Fecal elastase was normal in the six children in whom it was measured. No child had evidence of pancreatic or other disease, either at initial evaluation or during follow-up. The results of this study describe benign pancreatic hyperenzymemia in children. Although it is a benign condition, awareness of it is important to avoid unnecessary concern and multiple diagnostic procedures.

Day-to-day variations of serum pancreatic enzymes in benign pancreatic hyperenzymemia

BACKGROUND & AIMS

Benign pancreatic hyperenzymemia is a newly identified syndrome that is characterized by a chronic increase of serum pancreatic enzymes in the absence of pancreatic disease. When checked at intervals of months or years, the enzyme levels show considerable variation from one test to another, and enzyme normalization is sometimes seen. The purpose of this study was to determine whether these variations can occur on a day-to-day basis.

METHODS

Forty-two subjects with benign pancreatic hyperenzymemia, 28 men and 14 women, mean age 50 years, range 16-68 years, were studied. In each subject serum amylase, pancreatic isoamylase, and lipase levels were determined once daily on each of 5 consecutive days; in 15 of the 42 subjects studied, serum trypsin level was also measured.

RESULTS

In 8 (19%) of the 42 subjects, the serum enzyme levels were abnormally elevated for all 5 days of the study but showed wide fluctuations. In 33 (78.6%) subjects, the hyperenzymemia showed considerable day-to-day variations that included normalizations. In the remaining subject (2.4%), all enzymes were normal. In most of the subjects with hyperenzymemia, 37 of 41, all enzyme levels were elevated, with lipase, and trypsin when performed, showing the highest values. Of the remaining 4 subjects, in 3 only amylase and pancreatic isoamylase were increased and in 1 only lipase.

CONCLUSIONS

The results show that there are marked day-to-day variations, with frequent normalizations, of serum enzyme levels in subjects with benign pancreatic hyperenzymemia. The reason for these wide day-to-day fluctuations is not known.

Can pancreatic steatosis explain the finding of pancreatic hyperenzymemia in subjects with dyslipidemia?

OBJECTIVE

It has been proposed by some investigators that benign pancreatic hyperenzymemia could result from pancreatic steatosis that they believe would have been caused by dyslipidemia; their diagnosis of steatosis was based on the finding of a hyperechogenic pancreas at ultrasound. The aim of this study was to assess the validity of this proposed model.

METHODS

The study group was composed of 18 subjects with benign pancreatic hyperenzymemia, 12 men and 6 women; mean age, 55 years; range, 38 to 68 years. All 18 had dyslipidemia and 9 had hyperechogenic pancreas at ultrasound. In addition, 6 subjects with benign pancreatic hyperenzymemia but who did not have dyslipidemia or hyperechogenic pancreas and 10 healthy subjects with none of these conditions were also studied as controls. In each of these subjects, magnetic resonance imaging of the pancreas was performed to assess the presence of pancreatic steatosis.

RESULTS

Magnetic resonance imaging showed normal pancreas with no signs of fatty infiltration in all 18 subjects with dyslipidemia, including those with both dyslipidemia and hyperechogenic pancreas at ultrasound. A similar result was found in all control subjects.

CONCLUSION

The finding of a completely normal pancreas at magnetic resonance imaging does not support the proposed model in which pancreatic hyperenzymemia in subjects with dyslipidemia is attributed to pancreatic steatosis.

Mutations of the CFTR gene in idiopathic pancreatic hyperenzymemia

OBJECTIVES

Idiopathic pancreatic hyperenzymemia is a new syndrome that is characterized by a chronic increase of serum pancreatic enzymes in the absence of pancreatic disease. The aim of this study was to assess whether mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene may have a role in the etiology of this hyperenzymemia.

METHODS

Seventy subjects with idiopathic pancreatic hyperenzymemia, 44 men and 26 women (mean age, 48 years; range, 8-74 years), were studied. Thirteen of these 70 subjects had the familial form of the syndrome. The mutation analysis of the CFTR gene was carried out using diagnostic commercial kits for the simultaneous detection of 29 mutations and Tn polymorphism.

RESULTS

Among the 70 subjects studied, 7 (10.0%) had CFTR gene mutations. None of these 7 subjects had the familial form of pancreatic hyperenzymemia. These mutations were DeltaF 508 in 1 subject, 2789 + 5 G > A in another subject, and T5 allele in the remaining 5. All these mutations were heterozygous, with the exception of 1 T5 allele that was homozygous in 1 subject.

CONCLUSIONS

The frequencies of the mutations of the CFTR gene found in these subjects are similar to the carrier frequencies in the general Italian population. This finding does not support a role for CFTR gene mutations in the etiology of idiopathic pancreatic hyperenzymemia.

Effect of secretin on serum pancreatic enzymes and on the Wirsung duct in chronic nonpathological pancreatic hyperenzymemia

AIM

Chronic nonpathological pancreatic hyperenzymemia (CNPH) is a new syndrome characterized by an increase in serum pancreatic enzymes in the absence of pancreatic disease. The aim of this study was to increase our understanding of this condition by determining the serum pancreatic enzyme response as well as changes in the caliber of the Wirsung duct after secretin stimulation.

METHODS

Twenty subjects with CNPH and 9 healthy subjects without CNPH were studied. Blood samples were drawn 5 and 0 min before and 5, 10, 15, 30, 45, and 60 min after intravenous injection of secretin (1 U/kg). Amylase, pancreatic isoamylase, and lipase concentrations were determined. The caliber of the Wirsung duct was measured by ultrasonography.

RESULTS

The injection of secretin caused a marked and statistically significant (p < 0.05) increase in serum pancreatic enzymes in the subjects with CNPH that persisted for the duration of the study. The increase over the basal value was in the range of 1.2- to 1.6-fold for amylase, 1.4- to 2.1-fold for pancreatic isoamylase, and 2.6- to 4.2-fold for lipase. In the control subjects the increase was mild, but statistically significant (p < 0.05), ranging from 1.1- to 1.2-fold for amylase, 1.2- to 1.4-fold for pancreatic isoamylase, and 1.5- to 2.2-fold for lipase. The injection of secretin caused a slight increase in the diameter of the Wirsung duct in both groups of subjects, but this was statistically significant only during the first 30 min of the study.

CONCLUSIONS

The serum pancreatic enzyme response to secretin was more marked in CNPH than in controls. The Wirsung duct showed no alterations after secretin injection that would help to explain the hyperenzymemia.

Pancreatic hyperenzymaemia and hypertransaminasaemia in healthy subjects. Report of three cases

Three healthy subjects, two from Italy and one from the United States, showing a chronic increase in serum pancreatic enzymes and transaminases are described. The enzyme elevations reached very high levels but were not constant; rather, they fluctuated and sometimes returned to normal. Furthermore, tests for non-hepatic diseases that can be accompanied by an increase in serum transaminases, such as coeliac disease, were normal. The intervals between the first finding of the pancreatic hyperenzymaemia and the hypertransaminasaemia and this study ranged from 2 to 6 years (mean 4.3 years), during which the three subjects remained healthy, with no clinical, laboratory or imaging evidence of disease. These data support the conclusion that these increases in enzymes are benign; however, monitoring of these three subjects is already underway. Awareness of this anomaly is important, both to relieve the distress of the persons involved, as well as to avoid the numerous, sometimes invasive, complex and expensive examinations that might otherwise be unnecessarily performed.

A critical evaluation of laboratory tests in acute pancreatitis

An ideal laboratory test in the evaluation of a patient with acute pancreatitis (AP) should, in addition to accurately establishing the diagnosis of AP, provide early assessment of its severity and identify the etiology. None of the tests available today meet all these criteria, and presently there is no biochemical test that can be considered the "gold standard" for the diagnosis and assessment of severity of AP. In the diagnosis of AP, serum amylase and lipase remain important tests. Advantages of amylase estimation are its technical simplicity, easy availability, and high sensitivity. However, its greatest disadvantage is its low specificity. A normal amylase would usually exclude the diagnosis of AP, with the exception of AP secondary to hyperlipidemia, acute exacerbation of chronic pancreatitis, and when the estimation of amylase is delayed in the course of the disease. The major advantage of lipase is an increased sensitivity in acute alcoholic pancreatitis and in patients who initially present to the emergency room days after the onset of the disease, as lipase remains elevated longer than amylase. Although once considered to be specific for AP, nonspecific elevations of lipase have been reported in almost as many disorders as amylase, thus decreasing its specificity. Simultaneous estimation of amylase and lipase does not improve the accuracy. Other enzymes for the diagnosis of AP--pancreatic isoamylase, immunoreactive trypsin, and elastase--are more cumbersome and expensive and have no clear role in the diagnosis of AP. No enzyme assay has a predictive role in determining the severity or etiology of AP. Once the diagnosis of AP is established, daily measurements of enzymes have no value in assessing the clinical progress of the patient or ultimate prognosis and should be discouraged. A host of new serological and urinary markers have been investigated in the last few years. Their main use is in predicting the severity of AP. At present, serum C-reactive protein at 48 h is the best available laboratory marker of severity. Urinary trypsinogen activation peptides within 12-24 h of onset of AP are able to predict the severity but are not widely available. Serum interleukins 6 and 8 seem promising but remain experimental.