Normal Level Of Serum Lipase Research Articles

S1905 A Rare Case of Acute Pancreatitis With Normal Lipase

Introduction: Acute pancreatitis (AP) is an inflammatory disease of the pancreas that usually presents with epigastric pain radiating to the back. AP is a critical condition that can lead to multi-organ failure if not diagnosed early. It is diagnosed with 2 of the following: characteristic abdominal pain, imaging consistent with acute pancreatitis, and lipase levels greater than 3 times the upper limit of normal. The negative predictive value of lipase for diagnosing acute pancreatitis is between 94% and 100%. We present a rare case of acute pancreatitis with normal serum lipase levels. Our findings highlight the vital utility of imaging for diagnosing acute pancreatitis in the setting of normal lipase levels. Case Description/Methods: An 80-year-old female presented with a 1-day history of epigastric pain radiating to her back associated with nausea, vomiting, and loss of appetite. Her past medical history was significant for hypertension, NIDDM II, and atrial fibrillation. She had no recent medication changes and took amlodipine, metformin, metoprolol, and apixaban. Previous surgeries included cholecystectomy and appendectomy. She abstained from alcohol, tobacco, or recreational drug use. She reported abdominal trauma from bicycle collision one week prior to arrival. Vital signs were remarkable for T 101.2 F. She did not appear in acute distress. Her physical exam was remarkable for epigastric tenderness on palpation. Murphy, Cullen, and Grey-Turner signs were absent. Laboratory evaluation revealed WBC 12.8 k/uL, lipase 29 U/L, amylase 52 U/L, AST 13 U/L, ALT 21 U/L, ALP 58 U/L (Table). Lipid profile and EtOH levels were within normal limits. CT of the abdomen and pelvis revealed interstitial edematous pancreatitis (Figure). She was started on aggressive intravenous fluid resuscitation, metoclopramide for nausea, and intravenous acetaminophen for pain. Her abdominal pain progressively resolved, and she tolerated a full diet by day 3. Discussion: AP is a critical condition that requires early diagnosis. The negative predictive value of elevated lipase levels for diagnosing AP ranges from 94% to 100%. Our patient was diagnosed with acute pancreatitis due to trauma in the setting of normal lipase levels. We demonstrate the utility of imaging in diagnosing acute pancreatitis in the setting of normal serum lipase levels.Figure 1.: CT scan of the abdomen revealed peripancreatic fat stranding and interstitial edema consistent with findings of pancreatitis. Table 1. - Laboratory trends are displayed here. Lipase remained within normal limits through the 4 days measured. Admission Day 1 Day 2 Day 3 Day 4 Normal Range Hemoglobin 8.8 7.8 9.3 8.6 9.0 12.0 - 15.0 g/dL WBC 12.8 7.4 5.9 5.7 6.2 3.4 - 11.0 10*3/uL Amylase 52 39 29 - 103 U/L Lipase 29 12 13 - 60 U/L Calcium 8.9 8.1 8.9 8.8 8.4 8.4 - 10.2 mg/dL Alkaline Phosphatase 58 44 46 59 54 40 - 129 U/L ALT 21 16 29 17 11 10 - 50 U/L AST 13 10 14 12 16 13 - 39 U/L

Acute Pancreatitis in the Setting of Normal Serum Pancreatitic Enzyme Levels

There have been many reports of acute pancreatitis with normal serum amylase levels but acute pancreatitis with normal serum lipase levels is exceedingly rare. This is not uncommon given that amylase has a relatively short half-life of about ten hours with normalization in about three to five days while lipase may remain elevated for up to two weeks. A 44 year-old male with a past medical history of hypertension and diabetes mellitus presented to the Emergency Department complaining of nausea with non-bloody and non-bilious emesis, non-bloody diarrhea, epigastric pain, anorexia and chills for the past several days. The epigastric pain is sharp and radiates to the back. It is aggravated with food intake and lying supine. The patient admits to using alcohol every weekend and consumes several beers each session. His last alcohol intake was about one week prior. He denies tobacco or illicit drug use.His vitals on admission were notable for a fever of 101.5 degrees Fahrenheit and sinus tachycardia. The physical exam was notable for dry mucous membranes and severe epigastric tenderness with guarding.The remainder of the exam was unremarkable. His complete blood count and basic metabolic panel were within normal limits. Liver function tests were only notable for an elevated gammaglutamyl transpedtidase and an elevated lactate dehydrogenase. Serum amylase and lipase levels were found to be within normal limits. A lipid panel including triglycerides was also found to be within normal limits. A chest x-ray showed a small left-sided pleural effusion. The patient was admitted to the medicine service for the inability to tolerate oral intake and treatment for acute gastroenteritis.On day three of hospitalization, the patient was still not able to tolerate oral intake, developed worsening abdominal pain and a low grade fever. Repeat blood work revealed a white blood cell count of 15,300 cells per microliter. A Computed Tomography (CT) scan of the abdomen and pelvis with intravenous and oral contrast was pursued and showed extensive pancreatic edema and peripancreatic stranding consistent with acute pancreatitis. No pseudocysts or calcifications were seen. A repeat serum amylase and lipase were within normal limits. Based on clinical presentation and radiological findings, the diagnosis of acute pancreatitis was made. The patient was started on aggressive intravenous fluid hydration, pain management and bowel rest, with improvement in symptoms. On day five of hospitalization the patient was able to tolerate a regular diet with almost complete resolution of his epigastric pain. Clinical symptoms and radiological findings are all that is needed to make the diagnosis of acute pancreatitis and medical care providers should not exclude this diagnosis based on normal serum levels of amylase and lipase enzymes as they can normalize early on in the course of this disease.

Misdiagnosis of macroamylasemia in pregnancy as pancreatitis

Abstract Background: While elevated serum amylase in the presence of abdominal pain can be indicative of pancreatitis, differential diagnosis of macroamylasemia depends on additional assessment of serum lipase and urinary amylase. The present report concerns misdiagnosis of pancreatitis in a pregnant woman with elevated serum amylase but normal lipase. Highlights: The patient was a nulligravid woman on her first pregnancy diagnosed with pancreatitis in her 32nd week plus 3 days of gestation, on the basis of elevated serum amylase and abdominal pain, after treatment for premature contractions and antepartum vaginal bleeding with ritodrine HCl and nifedipine. She was started on painful and invasive intravenous hydration; oral intake was stopped. Repeat elevated serum amylase suggested that the patient might in fact have macroamylasemia, not pancreatitis. Conclusions: Normal serum lipase levels should be considered as a likely indication of an alternative cause of elevated serum amylase to pancreatitis, and urinary amylase should be routinely checked to assist in differential diagnosis to avoid unnecessary and invasive treatment and stress to pregnant women.

Macroamylasemia associated with thyroid cancer, elevated serum thyroxine-binding globulin (TBG), chronic pancreatitis and gastrointestinal polyposis

A case of macroamylasemia in a 78 year-old female, associated with papillary adenocarcinoma of the thyroid and elevated serum thyroxine-binding globulin was described. Serum amylase of the patient was very high despite a normal level of serum lipase. Her serum amylase was characterized as macroamylase on the basis of electrophoresis and elution profile of gel chromatography. Serum precipitation response using chain-specific rabbit anti-human IgG, IgA and IgM antisera disclosed that her macroamylase was mainly composed of immune complexes between amylase and IgA class anti-amylase antibodies. Both the pathogenesis and clinical significance of the association of these disorders in this patient were discussed.