Gastroduodenal artery pseudoaneurysm presenting with hyperamylasemia.

We present the case of a 75-year-old male admitted due to severe epigastric pain. His medical history was remarkable for chronic alcohol abuse, diabetes mellitus type 2, arterial hypertension, dyslipidemia. At admission he was hemodynamically stable. The initial workup showed elevated amylase, and the abdominal ultrasound excluded gallstone disease, so the diagnosis of acute pancreatitis was assumed. Despite appropriate fluid therapy, the patient developed hemodynamic instability. No signs of GIB were detected. An urgent laboratory workup revealed a new onset anemia and liver tests, including hyperbilirrubinemia. He underwent an urgent abdominal computed tomography with contrast, which showed a bleeding gastroduodenal artery (pseudoaneurysm and a hematoma adjacent to the second part of the duodenum. The patient underwent coil embolization achieving hemostasis without complications. GAD (pseudo)aneurysm is rare, accounting for 1.5% of all visceral artery aneurysms. Our patient presented with elevated pancreatic and liver enzymes, a more unique and challenging presentation since another more common differential diagnosis should be considered. The aneurysm can cause extrinsic common bile duct and main pancreatic duct pressure, which could explain the raised liver tests. Gastroenterologists should be aware of this rare and life-threatening entity, especially among patients presenting with common findings such as elevated amylase, jaundice, or altered liver tests. Hemodynamic instability is the main clue unmasking this diagnosis.

Hyperamylasemia may indicate the presence of ovarian carcinoma: A case report.

RATIONALE: Reports of malignant ovarian tumor with hyperamylasemia are very rare. We present a patient with hyperamylasemia who was diagnosed with a malignant ovarian tumor. PATIENT CONCERNS: A 46-year-old woman was hospitalized complaining of a 2-day history of abdominal discomfort and fever. On physical examination, she showed abdominal distention and tenderness, with rebound pain. Laboratory evaluation showed significantly elevated serum amylase levels. Computed tomography (CT) revealed a solid mass with uneven density in the pelvis. DIAGNOSES: Based on her clinical symptoms and hyperamylasemia, she was suspected to have acute pancreatitis at first. However, the final pathology showed advanced serous papillary ovarian carcinoma. INTERVENTIONS: She underwent initial therapy for acute pancreatitis, followed by laparotomy once her symptoms had disappeared. A tumor mass with maximum diameter 12 cm was detected originating from the right ovary, and the patient underwent hysterectomy, bilateral salpingo-oophorectomy with omentectomy, and appendectomy. On the 14th day after the surgery, she received 5 courses of chemotherapy with paclitaxel and carboplatin. However, distant metastasis before the 6th course of chemotherapy were detected by CT, she was therefore changed to a chemotherapy regimen containing gemcitabine and capecitabine. OUTCOMES: The final pathology showed advanced serous papillary ovarian carcinoma. On the 14th day after the surgery, she received 5 courses of chemotherapy with paclitaxel and carboplatin. However, her serum CA125 levels rose again before the 6th course of chemotherapy, and CT of the abdomen and pelvis revealed multiple abnormal-density lesions in the peritoneum and pelvic cavity. We considered these to be metastases, and the patient was deemed unresponsive to her previous chemotherapy. She was therefore changed to a chemotherapy regimen containing gemcitabine and capecitabine, and remained on this regimen at the time of writing. LESSONS: Ovarian carcinoma should be considered as a possibility in patients with hyperamylasemia after ruling out other potential common causes. The final diagnosis depends mainly on the clinical manifestation, laboratory results, and CT examination, though pathology is mandatory to confirm the diagnosis. The main treatment is surgical excision.

Urinary amylase/urinary creatinine ratio (uAm/uCr)--a less-invasive parameter for management of hyperamylasemia.

BACKGROUND: The serum level of amylase (sAm) is commonly used as a biochemical marker for diagnosis and management of pancreatic disorders. However, the use of the urine level of amylase (uAm) is limited in practice, because the diagnostic ability of uAm is inferior to that of sAm. In the present study, the possible concordance of uAm-rerated parameters with sAm was investigated, and evaluate the usefulness of uAm for management of hyperamylasemia. METHODS: From June 1995 to October 2009, 804 samples of both urine and blood were collected from 128 patients in order to measure the serum level of amylase (sAm) and the urine level of amylase (uAm) and creatinine (uCr). Concordance of parameters using uAm compared to sAm was assessed. Parameters used were uAm, amylase creatinine clearance ratio (ACCR), and the ratio of uAm to uCr (uAm/uCr). RESULTS: uAm/uCr had the best correlation with sAm (r = 0.779, p < 0.001) compared to uAm (r = 0.620, p < 0.001) and to ACCR (r = 0.374, p < 0.001), when sAm was over the standard level. The area under the receiver operating characteristic curve of uAm/uCr (0.884) was significantly higher than that of uAm (0.766) and of ACCR (0.666) (p < 0.001 for each). The cutoff value of uAm/uCr was 569.8, with a sensitivity of 81.0% and a specificity of 83.1%. CONCLUSIONS: The uAm/uCr ratio correlated with sAm, and may be an alternative to sAm for prediction of hyperamylasemia. Use of urine samples results in a decreased need for blood sampling, which is especially beneficial in pediatric patients.

Macroamilasemia en pediatría / Macroamylasaemia in paediatrics

La macroamilasemia es una entidad que debe sospecharse ante cualquier paciente que presente concentraciones elevadas de amilasa plasmática sin datos clínicos ni de investigaciones complementarias que demuestren la existencia de una afección pancreática o parotídea. Se caracteriza por la elevación de amilasa plasmática debido a macrocomplejos circulantes de alto peso molecular, formados por una molécula de amilasa unida generalmente a una inmunoglobulina. En ausencia de enfermedad renal, una hiperamilasemia sin aumento de amilasuria orienta hacia este diagnóstico, que se confirma al identificar a los componentes de la macromolécula. Es una entidad infrecuente en pediatría. Se ha descrito como un hallazgo casual asociado a dolor abdominal y a enfermedad celíaca. Se presentan 2 casos pediátricos de macroamilasemia, así como las pruebas necesarias para su diagnóstico. El conocimiento de esta anomalía bioquímica permite distinguirla de otras situaciones que cursan con elevación de amilasa, con el fin de evitar exploraciones complementarias y tratamientos invasivos innecesarios (AU)

Macroamylasaemia should be considered in any patient with high plasma amylase, no clinical signs and negative additional investigations for pancreatic or parotid diseases. It is characterised by an increase in serum amylase due to circulating high molecular mass macrocomplexes, most often formed due the binding of the amylase to an immunoglobulin. With a normal renal function, a hyper-amylasaemia without an increase in urine amylase suggests the diagnosis, and is confirmed by identifying the macromolecular components. It is an uncommon entity in paediatrics. It has been described as a casual finding associated to abdominal pain and to celiac disease. We report two paediatric cases of macroamylasaemia, and a review of the tests needed for its diagnosis. The better understanding of this biochemical anomaly allows us to differentiate it from other situations associated to hiperamylasaemia, in order to avoid additional invasive explorations and unnecessary treatments (AU)

Simultaneous complication of multiple myeloma with Sjögren syndrome.

We report a 72-year-old female case of IgG-kappa type multiple myeloma (MM) simultaneously complicated with Sjögren syndrome (SS). She also presented marked hyperamylasemia of salivary-type isozyme. Although she had received sequential chemotherapy completed with high-dose therapy with autologous hematopoietic stem cell transplantation, she died of relapse fifteen months after the initial diagnosis. Various autoantibodies indicated that her sicca symptoms were due to true SS and not caused by MM cell infiltration to exocrine glands. MM cells appeared to produce amylase that fluctuated correspondingly to the disease status of MM. To our knowledge, this is the first English report of simultaneous complication of SS and MM referring to hyperamylasemia. Accumulation of this rare clinical manifestation is important to elucidate the pathogenesis of MM under condition of immunological disorder caused by SS.