Serum lipase levels in nonpancreatic abdominal pain versus acute pancreatitis.

OBJECTIVE: 1) To determine whether serum lipase is elevated in patients with nonpancreatic abdominal pain, and 2) to compare the levels of serum lipase and serum amylase found in patients with nonpancreatic abdominal pain with those found in acute pancreatitis in order to differentiate between the two groups. METHODS: Serum lipase and amylase levels were estimated in 95 patients with nonpancreatic abdominal pain (group A). These levels were then compared with those found in 75 patients with acute pancreatitis (group P). RESULTS: Serum amylase in group A ranged from 11 to 416 U/L [mean 58 +/- 46 (SD)]. Three patients (3.3%) had raised amylase levels. The maximum elevation noted in this group was 416 U/L. Serum amylase in group P ranged from 124 to 13,000 U/L (mean 1620 +/- 1976). Twenty of the 75 patients (27%) in group P had levels that overlapped those found in group A. The serum lipase in group A ranged from 3 to 680 U/L (mean 111 +/- 101). Ten of the 93 patients (11%) had elevated lipase levels. The maximum elevation noted was roughly 3 times normal (680 U/L). Serum lipase in group P ranged from 711 to 31,153 (mean 6705 +/- 7022). None of the patients in group P had levels that overlapped those found in group A. The sensitivity of a serum lipase level > 3 normal in detecting acute pancreatitis was 100% and the specificity was 99%. The corresponding figures for serum amylase were 72% and 99%, respectively. CONCLUSION: A serum lipase level > 3 normal has a better diagnostic accuracy than serum amylase in differentiating nonpancreatic abdominal pain from acute pancreatitis.

Ingestion of corrosive substances by adults.

Compared with the ingestion of corrosive substances in children, this problem tends to be more serious, in adults, because its intent is often suicidal, rather than accidental. The severity and extent of damage produced to the gastrointestinal tract depends on the morphological form of the caustic agent. In the acute stage, perforation and necrosis may occur. Long-term complications include esophageal stricture, antral stenosis, and the development of esophageal carcinoma. X-rays of the abdomen and chest should be done initially to detect any evidence of perforation. Endoscopy should be performed as soon as possible in all cases to evaluate the extent and severity of damage, unless there is evidence of perforation. A complete examination is feasible in most cases. Stricture formation is more common in patients with second- and third-degree burns. Measures to prevent stricture formation, including the use of steroids, have not been successful. Esophageal carcinoma usually occurs 40 yr after the time of injury.

Lipase/amylase ratio. A new index that distinguishes acute episodes of alcoholic from nonalcoholic acute pancreatitis.

Because of observations that patients with acute episodes of alcoholic pancreatitis had high serum lipase levels whereas patients with gall stone pancreatitis had high serum amylase levels, a prospective study was undertaken to determine whether the ratio of serum lipase to serum amylase, a newly computed ratio, would discriminate between acute episodes of alcoholic and nonalcoholic pancreatitis. In phase one, 30 consecutive patients with acute pancreatitis were entered into the study and divided into groups A and B. Patients with renal failure were excluded from the study. Group A consisted of 20 patients in whom the etiology of pancreatitis was alcohol. Group B consisted of 10 patients whose pancreatitis was nonalcoholic in etiology (predominantly gallstones). Serum lipase values in group A ranged 492 to 25,706 U/L (median, 3433 U/L) and in group B from 711 to 31,153 U/L (median, 1260 U/L). These differences were not significant statistically. Serum amylase values in group A ranged from 104 to 2985 U/L (median, 331 U/L) and in group B from 423 to 13,000 (median, 1187 U/L). Although these figures were statistically different (P less than 0.005), there was a considerable degree of overlap in the values between the two groups. The lipase/amylase ratio calculated from the blood sample obtained at presentation appeared to be a promising discriminatory index. The lipase/amylase ratio was calculated by using the amylase and lipase levels expressed as multiples of the upper limit of normal in each case. The lipase/amylase ratios in the alcoholic group ranged from 2.2 to 14.8, whereas the lipase/amylase ratio in nonalcoholic pancreatitis ranged from 0.31 to 1.93. These differences were statistically significant (P less than 0.005). A lipase/amylase ratio of greater than 2 was indicative of an alcoholic etiology, and a ratio of less than 2 suggested that the pancreatitis was nonalcoholic in nature. In phase two, this lipase/amylase ratio of 2 was applied prospectively to an unselected population of 21 consecutive patients with acute pancreatitis. Thirteen patients had a lipase/amylase ratio of greater than 2; in 11 of them, the etiology of the pancreatitis was alcohol. Eight patients had a lipase/amylase ratio of less than 2; of them, only 1 patient had an alcoholic etiology for the pancreatitis. These differences were statistically significant (P less than 0.05).(ABSTRACT TRUNCATED AT 400 WORDS)

Pancreatic pseudocyst drainage--the needle or the scalpel?

A sizable number of pancreatic pseudocysts resolve spontaneously. Some, however, require intervention. Surgery was the only option available for many years. Recently, however, newer methods, such as percutaneous drainage and endoscopic cystotenterostomy have been used. Percutaneous drainage is inexpensive, has a low complication rate, and is done under local anesthesia. The recurrence rate is high with a one-time needle aspiration; this rate can be reduced to less than 10% by using an indwelling catheter. All these factors tend to make percutaneous continuous catheter drainage the first choice in the management of pseudocysts that require intervention. Experience with the endoscopic technique is still limited.

Tuberculous abscess of the liver in acquired immunodeficiency syndrome.

We present two human immunodeficiency virus (HIV) positive patients; each was diagnosed with tuberculous abscess of the liver and treated with good clinical response. A review of the literature indicates there is no typical clinical presentation. A high index of suspicion plus special stains of tissue material are required to make the diagnosis in appropriate patients, especially because this is a treatable condition even in patients with AIDS.

Bleeding from a tuberculous gastric ulcer.

A 26-yr-old male of Ecuadorian descent developed epigastric pain and bleeding per rectum, necessitating hospitalization. Upper endoscopy revealed an irregularly shaped gastric ulcer which was biopsied. Because of persistent bleeding and hemodynamic compromise, the patient underwent an exploratory laparotomy. Findings included peritoneal and visceral surfaces studded with small, round yellow lesions. Frozen section examination revealed granulomas with giant cells. Gastric biopsies from the endoscopy showed AFB. Although gastric involvement is seen in association with tuberculosis, the occurrence of upper gastrointestinal bleeding is unusual.

Gastrointestinal telangiectasias. A source of bleeding in patients receiving hemodialysis.

Endoscopy was used over a five-year period to determine the cause of acute or chronic gastrointestinal (GI) tract bleeding in 46 patients receiving long-term hemodialysis. Nine (19%) of the patients were found to be bleeding from telangiectasias. We observed the occurrence of such lesions in the stomach, the small bowel, and the colon. Endoscopic cauterization of the lesions in three patients and jejunal resection in another stopped previously recurrent GI tract bleeding.